



Class 



Book 



Gopyright^°___ 



COPYRIGHT DEPOSIT. 



A TREATISE 



ON THE 



PRINCIPLES AND PRACTICE 
OF MEDICINE. 



BY 

ARTHUR R. EDWARDS, A.M., M.D., 

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE 

NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, CHICAGO; ATTENDING 

PHYSICIAN TO MERCY, WESLEY HOSPITALS, ETC. 



ILLUSTRATED WITH 101 ENGRAVINGS AND 19 PLATES. 




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LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK, 

1907. 



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K 



ls> 



LI3RARY of CONGRESS 

Two Cortes Received 

MAY 1 1907 

h. Cepyrifht Entry . 
***** f.'"J<>7. 



CLA» 



A XXc.No, 
COPY B. ^ 



Entered according to Act of Congress, in the year 1907, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



LC Control Number 




tmp96 028692 



PREFACE. 



So wide is the range of Modern Practice that an author who would 
cover it in a single volume, and a reader who would grasp it intelli- 
gently, must approach their respective tasks with the aid of thorough 
system. In the following pages an effort has been made to deal with 
the subject in this manner, from its main divisions, which follow the 
most rational classification, down to the subordinate paragraphs. 
Careful use has been made of types of various prominence to facilitate 
the finding of a topic and the appreciation of its importance. With the 
vast mass of material, an attempt has been made so to arrange the 
facts that the reader may grasp the process of reasoning. 

Passing from these mechanical details to the characteristics which 
the author has endeavored to impress upon the book, it may be noted 
that, as far as possible, the causative pathology has been blended with 
the consecutive clinical features of disease, that reasons have been 
given for facts, that exceptions have been subordinated to what is 
usually found at the bedside, and that the allurements of typical clinical 
pictures and dogmatic generalizations have been avoided because they 
hold neither in practice nor at the postmortem table. 

The author also conceives that a book on Practice should be well- 
directed, which implies that it should deal adequately with scientific 
theories and principles, but that it should recognize that the final object 
of its existence is the application of knowledge to the cure or alleviation 
ofjfiisease. Accordingly, an unusual amount of space has been devoted 
to'*treatmenfc, to the detailed consideration of drugs and to numerous 
formula? and prescriptions ready for the student to use or improve 
upon. The physiological action of drugs has been dwelt upon care- 
fully because, in the writer's experience, the symptoms of disease are 
often confounded with those of the remedies exhibited for its cure. 

The reader will also find a large number of tables giving the differ- 
ential diagnosis of diseases likely to be confused, or in many instances, 
of entire subjects, such as those of the liver and kidney, the chief erup- 
tive diseases and those of the typhoid group. They are practical 
though necessarily schematic. Nowadays the border-lines of surgery 
and medicine overlap, and the practitioner, internist and surgeon must 

v 



vi PREFACE 

be familiar with the province of each other. . For this reason, as far as 
the scope of the treatise admits, surgical indications and results are 
introduced. 

The writer wishes to acknowledge the extremely careful attention 
bestowed by the Publishers upon every literary and typographical 
detail, and the assistance of Dr. F. G. Dyas and Dr. Milton Mandel 
in the proof reading. 

A. R. E. 

Chicago, 1907. 



CONTENTS 



Page. 



Section I. 



Specific Infections 17 



Section II. Diseases of the Circulation 377 



Section III. Diseases of the Respiratory Tract 



485 



Section IV. Diseases of the Digestive Tract 573 



Section V. Diseases of the Kidney 



767 



Section VI. Diseases of the Blood 



831 



Section VII. Diseases of the Ductless Glands 877 



Section VIII. Constitutional Diseases 



903 



Section IX. Diseases of the Nervous System 941 



Section X. Intoxications. Sunstroke 1241 



Section XI. Diseases Due to Animal Parasites 12 



bt 



SECTION I. 



THE SPECIFIC INFECTIONS 



TYPHOID FEVER. 

The name (Typhos, Stupor) refers to the clouded mentality, and 
dates from Hippocrates. The disease was first recognized by Louis of 
Paris (1829), and was first described as a separate disease by Gerhart 
and Pennock (1837). 

Definition. — Typhoid fever is a general infection, characterized — ■ 

1. Etiologically by the Bacillus typhosus. 

2. Anatomically by hyperplasia and ulceration of the lymphatic 
structures of the intestine, hyperplasia of the spleen and mesenteric 
glands, and by parenchymatous change in other organs. 

3. Clinically by a characteristic fever, roseolous eruption, enlarge- 
ment of the spleen, slow pulse, .a peculiar serum reaction, typhoid 
bacilli in the blood, and often by intestinal symptoms. 

Etiology. — The typhoid bacillus was first seen by Eberth and Koch 
(1880), and first cultivated by Gaffky (1884). 

1. Characters. — It has short, thick, rounded ends, is three times as 
long as wide, in length is one-third the diameter of a red blood-cor- 
puscle, and its numbers are usually, but not always, proportionate to 
the degree of infection. It is polymorphous, sometimes thread-like, 
varies in different media, contains no spores (though it is maintained 
that a spore is found at one pole), is flagellated, and actively motile. 
It grows best at body heat, and is a facultative anaerobe growing on 
various solid and fluid media, especially on agar, gelatin, and, char- 
acteristically, on the potato. It does not produce acid, ferment lactose, 
produce indol, or coagulate milk. It stains with aniline dyes, but not 
by Gram's method; is not inoculable, but produces the typhotoxin. 

2 17 



18 THE SPECIFIC INFECTIONS 

Until recently, animal inoculations have been negative. It is said 
that typical lesions have been produced in the chimpanzee. 

2. Location. — It is found in the ulcers, in the lymphatics of the mesen- 
tery, in the spleen, in the intestines at autopsy (chiefly in the upper 
small intestine), in the faeces, in the blood, in the internal viscera, in 
the urine, in the roseolae, less frequently in the lungs, muscles, uterus, 
oesophagus and tongue, and in various secondary foci, as in pleurisy, 
pneumonia (sputum), endocarditis, meningitis, parotitis, osteomyelitis, 
and abscesses. According to Lynch, it has also been isolated sixteen 
times from the blood of the foetus in maternal typhoid infections. In 
curious cases typhoid bacilli may occur in the stools of individuals, par- 
ticularly children, not suffering from typhoid fever. 

3. Tenacity. — Its tenacity of life is great, the germ persisting for years 
in bone lesions and enduring from three weeks to three months after 
death. It lives below zero, from two to twenty-two weeks. It resists 
drying, except in thin layers, for months, and lives some time in water, 
seldom longer than three weeks, although its multiplication is pre- 
vented by saprophytes. It is killed in a few hours by direct sunlight. 
The germ may live for months in ice, sour milk, faeces, or in the up- 
per, but not in the deeper, layers of the soil. It may live a year in soiled 
clothes, which explains contagion in washerwomen and nurses. 

4. Entrance. — It resists gastric juice fairly well, yet its chief and 
probably sole atrium is the digestive tract, the infection being carried 
in water (its main medium), milk, butter, ice, vegetables, or oysters. 
As shown in the Spanish-American and Boer wars, dried faeces con- 
taining the bacilli may be carried by flies and sand. Alice Hamilton 
found the bacilli in flies in the Hull House region of Chicago. Cock- 
roaches and other insects may also convey infection. 

5. Exit. — The germ leaves the body chiefly in the faeces and urine, 
which are dangerous even far into convalescence, and which are the 
chief means of dissemination, the disease being less often conveyed 
directly from one individual to another, although direct infection occurs 
in hospitals and camps. Lenz found that certain persons after a 
typhoid attack become "chronic carriers of typhoid bacilli," the bacilli 
remaining in their dejecta for one or even fifteen years. 

From a practical standpoint, the direct etiological diagnosis is of 
somewhat limited value, since (a) differentiation from the colon bacillus 
requires an expert bacteriologist; (b) the bacillus does not appear 
early nor invariably in the stools, where the diagnosis is difficult; and 
(c) since direct splenic puncture for diagnosis alone is no more justifi- 
able than in malaria. The bacillus itself is found in the blood early 
in the first week. In the second week the serum usually gives the 
distinctive Widal reaction. 

Predisposing Etiology. — 1. Reduced pyhsiological resistance, as 
from overwork or mental depression, is a frequent predisposing cause; 
yet typhoid very often occurs in the robust. It is claimed that the 
weak or emaciated are immune, — e. g., those with syphilis, tubercu- 
losis, cancer, endocarditis, anaemia, or convalescents from other dis- 



TYPHOID FEVER 19 

eases. Some immunity is claimed in pregnancy, lactation, and the 
puerperium. Alimentary affections, according to Bouchard, such as 
decreased hydrochloric acid formation, or dilated stomach, favor 
infection. Most cases occur in time of war, or among the poorer 
classes, or among recent residents in typhoid localities. 

2. Season. — For reasons not known most cases develop in the late 
summer and fall ("autumnal fever"). 

3. Age. — The years from fifteen to twenty-five include most cases 
(56 per cent.), yet foetal cases are recorded, and a few cases occur in the 
first year of life. Their number increases from the first to the fifth 
year. Between the fifth and fifteenth years as many are affected as 
after thirty-five. The disease is relatively rare after fifty. 

4. Geographical Distribution. — Typhoid is endemic rather than 
epidemic. Although it is the most common continued fever in tem- 
perate climates, it is a world-wide disease and sustains a most intimate 
relation to the water supply, the disposal of sewage, the density of 
population, and personal hygiene. 

Immunity. — Congenital immunity is not proved. Immunity has no 
relation to the severity of the disease, though it is usually conferred 
after one attack, but is not life-long nor as frequent as in the case of 
scarlatina. In the Hamburg epidemic (1887), 2tg per cent, of the 
cases were second attacks; and in Eichhorst's series there were over 
4 per cent, of second attacks. These second attacks equal or even 
exceed the original in severity. 

Symptoms. — The general clinical picture offers more variability 
than that of any other infection. Typhoid is not an intestinal disease, 
but a general infection. Its forms are: 

1. The typical enteric, frequently with diarrhoea, tympany, hemor- 
rhage, and perforation. 

2. The septiceemic, without any, or with very slight, anatomical 
intestinal lesions, though responding to the Widal test and accom- 
panied by bacillsemia. 

3. Other localizations than enteric; e.g., in the lung, larynx, bone, 
etc. 

4. Mixed infections — malaria, streptococcus, colon bacillus, etc. 

5. Paratyphoid, with close clinical resemblance to typhoid but with 
organisms differing culturally and in their agglutinating reactions. 
(See Diagnosis). 

The incubation lasts one to two weeks, with symptoms more vague 
than in other acute infections, — e. g., depression, pains in the head, 
back, or limbs, dulness of hearing, disturbed sleep, or perhaps chilli- 
ness, night-sweats, anorexia, epigastric oppression, constipation, or 
even diarrhoea. The incubation lasted only three days in a girl who 
took a pure typhoid culture with suicidal intent. 

The first week corresponds anatomically to the intestinal catarrh 
and the beginning of medullary infiltration of Peyer's plaques. The 
disease dates from the fever, which each evening is from 1° to H° 
higher than on the previous day, until a temperature of 103° to 104° is 



20 THE SPECIFIC INFECTIONS 

reached. The pulse is full, dicrotic, and rapid, but not high in propor- 
tion to the fever. The tongue is coated white. Thirst, dry cough, 
enlarged spleen, eruption of rose spots, and typhoid bacilli in the 
blood, are found. The abdomen shows slight distention and ten- 
derness over the ileocecal region or epigastrium. Delirium is infre- 
quent, and headache, constipation, dulness and apathy are usually 
present. 

The second week corresponds to the end of medullary infiltration 
and the beginning of eschar-formation. The fever is higher and usually 
continuous. The morning remission is less. The pulse is full, faster, 
and less dicrotic. The blood responds to the Widal test. The tongue 
is dry and glazed, as are also the lips, pharynx, and mouth, to which 
the mucus adheres. The voice is weak. The bronchitis increases, 
and- the urine is febrile. Abdominal symptoms are often aggravated. 
Meteorism appears. Yellow pea-soup dejecta, which are involuntary 
in severe cases, occur. The face is apathetic, its lines obliterated, the 
mouth half open, and the upper lip retracted, showing sordes. 
Roseolas usually develop during this week. Nervous symptoms in- 
crease with higher fever; delirium follows; the patient becomes 
less querulous; and euphoria from narcosis by the toxins is the rule, 
while pain suggests complications. The patient may begin to recover, 
or may die at this stage from hemorrhage or nervous toxaemia. 

The third week is the stage of ulceration. The fever gradually de- 
clines with marked morning remissions and unaccountable variations. 
The pulse is smaller, and faster (100 to 120), and loses its dicrotism; it 
is sometimes slower. The tongue clears and the roseolas disappear, 
being replaced by miliaria from sweating. In exceptional cases diar- 
rhoea may be seen for the first time in this week. Emaciation is marked. 
When the fever falls, the patient complains of hunger, weakness, and 
pain. Death may occur in the typhoid state from heart weakness, 
pulmonary inflammation, paralysis of the nerve-centres, hemorrhage, 
or perforation. 

The fourth week (cicatrization) usually marks convalescence, as the 
average duration of typhoid is from three to six weeks; though in 
severe cases the symptoms assigned to the third week may continue. 
Convalescence may be uneventful, or marred by slight temperature, 
rapid pulse, palpitation, nausea, vomiting, muscular weakness, exag- 
gerated reflexes, etc. 

Symptoms in Detail. — To avoid repetition, and to explain anatomi- 
cally the clinical signs and symptoms, the typhoid pathology will be 
incorporated under the appropriate organs, and complications and 
sequels will be classified with the more common typhoid manifesta- 
tions. 

1. Fever. — Fever is an expression of toxaemia, and is a cardinal 
symptom of typhoid. It is subacute. It lasts more than fourteen 
days (averaging three to four weeks), usually comes on without chill, 
and resolves by lysis. It is the best studied chapter in the disease 
since the time of Wunderlich, who in dubious cases diagnosticated 



TYPHOID FEVER 



21 



typhoid from the fever chart alone. In its incipiency there is usually a 
gradual rise for three to five days. Wunderlich placed great stress 
upon this, though the rise is sometimes sudden or accompanied by a 
chill. Choniel (1834) described cases with sudden onset and De 
Mussy (1884) spoke of an explosive onset; a sudden onset is observed 
in 10 per cent, of typhoid cases. The writer saw, with Dr. Korssell, a 
child whose temperature rose suddenly to 106° on the second day. 

In the first week, corresponding to the catarrh and medullary infiltra- 
tion, the evening temperature is to° to 1° more than in the morning, 
and the ascension is ladder-like. When there is an initial chill, every 
other possible disease should first be excluded, yet Osier observed 
chills in 24 per cent, of his cases. Chills occur: (a) at the onset, espe- 
cially in children, and in light forms; (b) throughout the course, and 
accompanied by sweats, the sudoral type of the French; (c) in compli- 
cations — pneumonia, pleurisy, otitis media; (d) after antipyretics, 
tubbing, or (e) in defervescence, sometimes from secondary sepsis. 









Fig. 


1. 










PL LSE 


1 Days G 


12 


is 


24 


so 


sG 
























aAA^ 


A/W 


\ A i 








130 


ft 


r 




M 


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1,0 


f 






V 


I 


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100 


S 




/ V 


ij 


\M 






00 


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mu 






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,*\ 


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NORMAL 








» 


» \l\ • 
















' Wv 


V ' 



















CONTINUOUS 



FEVER REMITTENT INTERMITTENT SUBNORMAL; 

FEVER FEVER CONVALESCENCE 



Typical typhoid-fever curve. — The heavy line marks the temperature curve, and the broken line 

the pulse curve. 

In the second week, corresponding to the end of infiltration and to 
the formation of the slough, the fever is continuous from one-half to 
three weeks, Curschmann distinguishing two types: (i) one and one- 
half weeks fastigium, and (ii) three weeks fastigium. Especially high 
temperature suggests complications; if the fever becomes very high, 
the course is apt to be severe. Sometimes a pseudo-collapse may occur, 
particularly in subjects between twenty-five and thirty years of age. 

In the third week (ulceration), the fever is remittent, the amphibolic 
stage of Wunderlich, and the stadium hecticum of Traube. The cause 
of fever variations is not known. 

The fourth week (cicatrization) is the stage of "steep curves," lasting 
from three to eight days. When a sudden drop occurs, recurrences 



22 



THE SPECIFIC INFECTIONS 



and relapses are not infrequent. A critical fall of the temperature 
sometimes follows. Jaccoud observed a brusque defervescence in 29 
per cent, of his cases. The fever may be intermittent or remittent 
throughout the disease, especially in children, the aged, and in severe 
cases. Irregularity and variations, especially when protracted, cause 
difficulty in diagnosis, suggesting, perhaps, miliary tuberculosis or 
sepsis. 

Fig. 2. 



DAY 1 2 3 4 5 7 SO 10 11 12 13 14 15 Hi 17 13 ID 20 21 22 23 24 25 20 27 28 29 30 31 32 


TEMP. 


101 






103 A 1 j 


A A l / ■ 1 • 


i A, 4- -r- ft T -A A-Jh- -t 1 


102 i M A k A/ w 


\ \ ' nWv A i V |i i 


a v i, i r i A n " / 


101 * \A j i^ 'V ' l . 


V V V "v 11 


M v j j 


100 i 


V I v 




99 


1 ' 


1 


98 






,. _ 



Typhoid fever; irregular fever curve throughout the course. 1 



T Convalescence, — In its first week the fever-curve is usually sub- 
normal; when not so, some irregularity must be looked for. Later 
there is a gradual rise to normal. 

In the typus inversus, seen chiefly in children and the aged, the 
morning temperature is higher than the evening record. Afebrile 
typhoid is exceptional. Modification of temperature may be caused 
by visits from friends, excitement, entrance to the hospital, diet, hem- 
orrhage, abortion, peritonitis, and other complications. 

2. The Splenic Tumor. — The splenic tumor is a cardinal symptom 
occuring early and frequently, persisting in exacerbations and relapses. 
In importance and size, it ranks second to the splenic enlargement of 
malaria and sepsis. The cause of this tumor is the bacillus or its 
toxins (not the fever) which produce splenic hypersemia and hyper- 
plasia — changes closely analogous to those in the intestinal lymph- 
structures. Massive endothelial proliferation is said by Mallory to 
occur in the splenic, lymphatic, and medullary vessels. In the first 
week the spleen is hypersemic and swollen to two or even three times 
its normal size. Its markings are indistinct. In the second week 
it is more pulpy and darker. By the fourth week it has usually dis- 
appeared, but as long as we find the splenic tumor, the disease has 
not ended. 



TYPHOID FEVER 23 

Frequency. — (a) Anatomically the .splenic tumor is present in 98.4 
per cent, of the cases. Its rare absence is explained by thickening of 
the capsule, old induration or infarction of the organ, or extreme 
emaciation, (b) Clinically, it is present in 75 to 80 per cent. (Cursch- 
mann) or 90 per cent. (Leube). The percentage varies with the skill of 
the observer, the method of examination, the epidemic, and age of 
the subject (the sign being often absent in children, in adults older 
than forty-five years, or after hemorrhage). It should be palpated 
with the patient in the right diagonal position. This is difficult in 
pain, tympany, and in an anomalous position of the colon. The author 
has twice seen the spleen ruptured by deep or rough palpation. Per- 
cussion of the spleen is worthless. It should be remembered that the 
spleen may be ectopic. The examiner should stand or sit on the right 
side of the patient, palpating with the right hand pressing evenly on the 
abdomen, and the left hand hooked beneath and lifting up the lower 
left ribs. Relatively rare splenic complications are abscess, infarcts 
and rupture. 

3. Dermal Symptoms. — (a) Rose Spots (roseola ' typhosa, tdche 
rosee lenticulaire of Louis) constitute the third cardinal symptom. 
They are round spots, varying from the size of a pin-head to that of a 
lentil (lenticular), circumscribed, rose-colored, slightly elevated to the 
touch, purely hyperaemic, and therefore disappearing on pressure and 
reappearing on its release, not often fusing, and later becoming darker, 
but leaving no mark, with sometimes a vesicle at their apex, and rarely 
desquamating, except in a few infantile or juvenile cases. They are 
rarely hemorrhagic, and therefore the commonly used term, petechia, 
is inappropriate. Being purely hypersemic, they are not found at 
autopsy. They scarcely ever pustulate. They may be seen as early as 
the fourth day, especially in women and children, but usually appear 
from the seventh to the tenth day. They occur in crops, during two 
weeks, each crop lasting from three to five days. Occasionally, they 
outlive the fever. Their location is on the lower breast and abdomen, 
though they sometimes appear twenty-four hours earlier on the back, 
because of its warmth. They rarely occur on the neck or face, and 
generally are more frequent on the proximal than on the distal parts 
of the extremities. If there are many on the lower parts of the limbs, 
they are probably not roseola?. They number five to ten, or even thirty. 
They are more abundant in women, less so in children and the aged, 
and seldom so abundant as to resemble measles closely. Their fre- 
quency varies somewhat with the epidemic. Eichhorst found them 
in more than 1,200 cases, Leube in 80 per cent., Osier in 93 percent., 
and Murchison in 33 per cent. 

Typhoid bacilli have been found in the roseola? in 50 to SO per cent. 
of the cases and may establish a doubtful diagnosis, but, of course, 
rarely an early one; Polacco found the bacilli in 100 per cent, and 
Krause in 94 per cent, of their cases. In other diseases, as miliary 
tuberculosis, meningitis, tuberculosis, and pneumonia, they are very 
rarelv encountered. 



24 THE SPECIFIC INFECTIONS 

(b) Other Cutaneous Manifestations. — Other cutaneous mani- 
festations are: urticaria; erythema, even of the nodose or exudative 
forms; pelioma typhosuni, or the tache bleudtre — pale blue spots meas- 
uring 4 to 10 millimeters, due to pediculosis, and therefore seen in parts 
nearest the pubic or axillary hair, etc. ; erysipelas, phlegmon and fu- 
runcles (increased by hydrotherapy) ; alopecia after the typhoid attack, 
rarely followed by permanent baldness. The typhoid odor is musty 
or semi-cadaveric. Miliaria are frequent, though less than in sepsis 
and more common than in measles or scarlatina. They usually appear 
late in the third or fourth week. Herpes is rare, occurring in less than 
1 per cent, of the cases. The author has observed it only ten times in 
upwards of 1,800 cases. It is far less frequent than in pneumonia, 
malaria, typhus, meningitis, and influenza. Decubitus occurs in 1 per 
cent., mostly in severe and hospital cases. Noma is a rare complica- 
tion. In 204 cases of gangrene collected by Keen, 50 per cent, occurred 
in the leg, 25 per cent, in the face, neck, and trunk, and the balance 
in other locations. McFarland and Hare have reported a number of 
cases in Philadelphia. Sweats and chills occur in the ' ' typhus sudor- 
alis," especially in the latter half of the fever course, described in 
Naples by Borelli and in Paris by Jaccoud. (Edema is due most 
frequently to phlebitis, sometimes to anaemia, and rarely to nephritis. 
The skin sometimes shows atrophic strias like those of pregnancy. 
Desquamation may occur, particularly, in children. 

4. Circulation. — (a) The Slow Pulse. — The slow pulse is the fourth 
cardinal symptom. In uncomplicated cases it follows the temperature 
in the early stages, but is lower than the fever would justify, especially 
in men under forty years ; e.g., pulse 90 with the fever 103°. It is rather 
faster in women, in children, and in the nervous. Its slowness is due 
to an inhibitory action of the toxins on the medulla or the heart, a fact 
not recognized either by the older or by some of the modern writers. 
The author has seen four typhoid cases in which the pulse ranged from 
fifty-six to sixty-four, with the fever above 103° and the respirations 
above forty. Slowness is of good import. A fast pulse early in the 
typhoid course is a poor prognostic, especially in men. Irregularity 
or crossing of the pulse and temperature-curves, is also ominous. 
The pulse may become faster from heart or lung inflammation, perfora- 
tive peritonitis, hemorrhage, and severe intoxication. It may also 
run up on visiting days, in women, children, emaciated and nervous 
individuals, or in the stage of great temperature variations. At first a 
little tense in volume, it soon becomes dicrotic, which, with slowness, 
suggests typhoid. Dicrotism, evidenced by a double shock, occurs in 
80 per cent, of cases, but is not prognostic. It is usual in adults, is 
absent in children and often in adults at the fastigium in very severe 
cases. Since it indicates lack of arterial tone, it is also absent in arterio- 
sclerosis. In Osier's Clinic, the blood-pressure was found to be 115 to 
125 millimeters of mercury in the systole, and 85 to 100 millimeters in 
diastole. In the first stage of convalescence, when there is subnormal 
temperature, the pulse is usually normal in rate, or slow, which is ex- 



TYPHOID FEVER 25 

plained by disturbed conductivity in the heart muscle. Myocarditis 
is possibly the cause in some cases. In the second stage it is usually 
higher than normal, especially after the patient gets out of bed, after 
eating, or a movement of the bowels. On the whole, bradycardia in 
convalescence is more common than tachycardia. 




Pulse tracing in typhoid, showing di erotism. 

(b) Heart Muscle. — In the heart muscle early changes are rare. 
Parenchymatous degeneration, evidenced by albuminous granules, 
nuclear swelling, and pigmentation, are found later, the heart as a 
whole being flabby, soft, pale, and even waxy. Fatty and hyaline 
degeneration, vacuole formation, segmentary myocarditis, and a ten- 
dency toward muscle regeneration, are the usual findings in fatal 
cases. Interstitial myocarditis, like that of diphtheria or scarlatina, 
occurs in over 50 per cent, of typhoid cases (Rhomberg). It usually 
regresses without functional or organic disturbance, and chronic myo- 
carditis rarely develops. Its clinical signs may appear at the end of the 
second week, and last into the fourth week, or it may develop first in 
convalescence. The symptoms are gradual dilatation, weak tones 
(especially the first tone at the apex), accentuation of the second pulmonic, 
asystolic bruit, and a fast, irregular pulse with lessened tension butwith- 
out dicrotism. Tachycardia, without myocarditis, may result from the 
toxins acting on the medulla oblongata. Recovery is usual, even if the 
myocarditis lasts two or three months. 

Dilatation of the right heart may be observed in severe cases. Less 
frequent are the following complications: Cardiac thrombosis and 
embolism; pericarditis ([one in 1,000 autopsies], mostly fibrinous, and 
mostly in complicating sepsis); endocarditis ([one in 1,000], mostly 
mural over myocarditic patches), sometimes due to Eberth's bacillus; 
collapse, with its usual signs, which may cause death from heart de- 
generation, or from toxic vasomotor paralysis (as in diphtheria, pneu- 
monia, or pyocyaneus infections). Myocarditis is the most common 
cause of collapse, while pulmonary embolism, ursemia, cerebral hemor- 
rhage, etc., are far less common. Sometimes no clear cause is discovered 
at autopsy. Collapse develops mostly in strong men (SO per cent, of 
D.ewevre's 140 cases) and most often during convalescence. (See Prog- 
nosis.) 

(c) Vessels. — In the vessels, arteritis typhosa, most often found in 
the femoral artery, is rare, W. W. Keen collecting only forty-four 
cases. It is a specific inflammation caused by the typhoid bacillus. 



26 THE SPECIFIC INFECTIONS 

Spontaneous gangrene may result. Arterial embolism from marantic 
thrombi is rare. Phlebitis typhosa occurs in 1 per cent, (to 2.6 per cent., 
Thayer) of the cases, being considered marantic or infective (Eberth's 
bacillus or pus cocci), when pain and fever are present; it occurs 
chiefly in males, is unilateral and is usually left-sided, since the left 
vein has a slower current, being crossed by the right iliac artery 
(Liebermeister). The symptoms are pain, coldness, oedema, and some- 
times a tender, palpable cord, which should be manipulated most 
carefully, if at all, lest embolism be caused. Thrombosis usually occurs 
in the saphenous vein where it empties into the femoral, sometimes 
in the popliteal vein, and rarely in the arms. It may extend from the 
leg to the cava, when the other leg may be involved. There is some 
danger of detachment, pulmonary embolism, and sudden death; but 
relative recovery is usual after two or three months. 

(d) The Blood.— The red blood-cells average 4,000,000. Their 
reduction is always slow, and anaemia is especially frequent dur- 
ing the third week or in relapses. An apparent increase of the red 
disks, analogous to that observed in cholera, may result from loss of 
fluids, as from diarrhoea (Hayem). The hsemoglobin decreases pro- 
portionately to the red cells, or slightly in excess of the oligocythsemia, 
especially in convalescence. Marked post-febrile ansemia is not com- 
mon. The leukocytes decrease from 8,000 to 3,000, or even less, but 
average 5,000 per cubic millimeter. Occasionally, large cells containing 
numbers of red corpuscles are seen. Leukopenia is more common in 
typhoid than in any other febrile condition and helps to differentiate 
it from pneumonia, sepsis, meningitis, etc. It is possibly due to destruc- 
tion of the lymphatic elements by the endothelial phagocytes. In- 
crease of the white cells occurs only in complicating inflammations or 
in convalescence. The polymorphonuclear neutrophiles are absolutely 
and relatively decreased to below 50 or 60 per cent., while they are 
increased in other infections. The large mononuclear and transitional 
forms are relatively increased. The eosinophiles are greatly decreased; 
their return is a good prognostic (Tiirck). 

The Gruber-Widal serum test is based on Pfeiffer's experiments on 
immunity in cholera (1884). Pfeiffer and Kolle not only produced 
immunity, but found that bacteriological inoculations in animals be- 
came granular and gradually dissolved. Metschnikoff and Bordet 
found the same reaction in the test-tube with the blood-serum of ani- 
mals. The " agglutination 5 ' and "immobilization" of typhoid bacilli 
brought in contact with a typhoid serum, was found by Durham and 
Gruber, and also independently by Pfeiffer and Kolle. Gruber pointed 
out the value of the test in proving the existence of a previous typhoid, 
while Widal applied the laboratory facts at the bedside, and found the 
reaction during the disease. The agglutinating substances may pass 
from the maternal blood to that of the foetus, or from the mother's milk 
to the infant's blood; they may be obtained from the serum of a blister 
and sometimes from the urine, saliva, semen, tears, or cerebrospinal fluid. 
Technique. — A bouillon culture, not more than twelve to eighteen 



TYPHOID FEVER 27 

hours old, is used, taking forty parts of the bouillon and one of the 
blood (dilution of 1 to 40). The test may be made macroscopically 
in the test-tube, or on the microscope slide, where immobilization, 
clumping, agglutination, and final solution of the bacilli, may be 
observed, sometimes in a very short time — an hour is the usual time- 
limit for the test. Ficker and Ruediger have recently employed dead 
cultures with equally accurate results, and this method is certainly 
more convenient, safe, and capable of wider use than the use of living 
bacilli, especially in country practice. (Plate I.) 

Significance. — The Gruber-Widal reaction may be found thirty 
years after a typhoid attack. Occasionally it is found in rheumatism, 
sepsis, miliary tuberculosis, meningitis, pneumonia, influenza, endo- 
carditis, or icterus, and it is sometimes absent in typhoid. While pres- 
ent in 95 to 97 per cent, of typhoid cases, it often develops late; e. g. } 
on the seventeenth or the fortieth day. Cabot found the reaction in 
97 per cent, of 5,978 collected typhoid cases. In Osier's series it ap- 
peared in 93 per cent, before the eighth day. When it appears in the 
first week, it is due to a "silently developing'' infection (Widal); i. e., 
the typhoid is more advanced than we appreciate. Leube considers 
the test significant only when it is absent in the early stages and develops 
later, care being necessary in all other cases whether the reaction 
be positive or negative. The author has long since ceased to exclude 
typhoid absolutely when no reaction is obtained, and he maintains the 
importance of the classic symptom-complex even without the serum 
reaction. Undue importance is sometimes attached to this as well as to 
many other laboratory tests, invaluable though they may be in connec- 
tion with the physical findings. In severe typhoid the test may be 
absent, when early cultures (in 85 to 94 per cent, of the cases) may 
reveal typhoid bacilli in the blood. Kasel and Mann believe the re- 
action is not one of infection, but one of immunity, agglutination 
becoming most marked toward the end of the disease. 

Typhoid bacilli have been cultivated from the blood in a large per- 
centage of cases (even 88 and 94 per cent.), and undoubtedly are present 
in the blood of every case. In an analysis of 535 cases, Rosenberger 
found bacilli reported in 80 per cent. 

5. Nervous Symptoms. — Typhoid was once called "nervous fever" 
(febris nervosa, nervenfleber). The nervous system may be conspicu- 
ously involved even in the incubation stage. 

(a) Headache. — Headache is almost invariable, being most often 
frontal or occipital, constricting, throbbing, or a pressure sensation. 
It usually disappears in the second week, and, if it lasts or develops 
late, it may indicate meningitis. Insomnia may be both early and 
lasting. Stupor and sleep must be distinguished from one another, 
since a patient may be stuporous yet sleepless. 

(b) The Typhoid State. — The typhoid state begins in the second 
week (v.s.) with apathy and delirium, which is usually mild. The 
patient may attempt to get out of bed, and, in alcoholics, delirium tre- 
mens may be simulated or actually develop. In mild cases delirium 



28 THE SPECIFIC INFECTIONS 

lasts into the third week. In very irritable subjects, as in women and 
children, or in overwhelming intoxication, we may have photophobia, 
stupor, coma, loud breathing with an open mouth, absence of the 
pharyngeal reflex, involuntaries, waving of the hands (floctitation), 
leaping of the tendons (subsultus tendinum), picking of the bedclothes 
(carphologia), trismus, contractures, grinding of the teeth, rigid neck, 
and convulsions (in children especially), which symptoms are not due 
to the fever, since they all may occur with low temperature, but to 
toxaemia. In coma-vigil the patient is semi-comatose subjectively, but 
the open, unseeing eyes give a " watchful" appearance objectively. 
Anatomically a "wet-brain" is found. Murchison observed convul- 
sions but six times in 2,960 cases. They may develop in children, in 
severe intoxication, or from such cerebral complications as meningitis, 
encephalitis, thrombosis, or embolism. 

(c) Nervous Complications. — Typhoid may begin as mania. 
The author has seen five typhoid patients taken to the detention hos- 
pital in the third week, or even in convalescence, under a mistaken 
diagnosis. It may be a later though generally a rare symptom. 

Psychoses are generally post-febrile, are of the depressive variety 
such as melancholia, and usually give a favorable prognosis, though 
alienists assert that one-third to one-fifth do not recover. Edsall 
(1905) found that two-thirds of juvenile cases recover. Their cause 
is the exhausting inanition of protracted toxaemia, or sometimes a 
hereditary predisposition. Typhoid may cure a previous insanity. 

Meningitis is usually cerebrospinal and occurs in 0.5 per cent, of the 
cases, mostly in women and children, generally as a complication and 
late in the typhoid course during the period of " steep curves." Men- 
ingitis may be due to the pneumococcus, the pyogenic cocci, or to 
Eberth's bacilli, which have been found on lumbar puncture in over 
twenty-six cases (Cole), of which half were serous and half suppura- 
tive. Mastoiditis as well as tuberculosis may cause the meningitis, 
there being four recorded cases of the tuberculous variety. Actual . 
meningitis must not be confounded with pseudomeningitis or "menin- 
gismus," in which toxaemia produces irritative meningeal symptoms, 
as above enumerated. 

In the brain, oedema, degenerated and pigmented ganglionic cells, 
and nuclear multiplication, are the most common findings at the 
autopsy. Hemorrhage, embolism, arterial and sinus thrombosis, 
and abscess (sepsis), are rare pathological complications. Aphasia, 
monoplegia, hemiplegia, and paralysis of the cerebral nerves, are rare 
clinical complications. The author has twice noted hemiplegia devel- 
oping suddenly in convalescence, probably embolic from detached heart- 
clots. In both cases the patients were allowed to leave the bed too 
soon. Hawkins has noted seventeen cases of hemiplegia in typhoid. 

In the spine, myelitis, multiple sclerosis, infantile paralysis, and 
Landry's paralysis (Eberth's bacillus), are the most common complica- 
tions or sequels. The knee-jerks are sometimes increased, especially 
in emaciated subjects. 



TYPHOID FEVER 29 

Neuroses may complicate convalescence, such as chorea, hysteria, 
neurasthenia, catalepsy, Basedow's disease, tetany, paralysis agitans, 
diabetes insipidus. 

In the nerves, neuritis in the single or multiple form (q.v.) with 
anaesthesia, paralysis, and atrophy, may follow typhoid as it does other 
infections. Neuralgia occurs late. In the feet it constitutes the " ten- 
der toes" of Hanford, and is seemingly increased by bath treatment. 
It always results in recovery. 

6. Special Senses. — The eye is rarely involved. Muscle paralysis 
(neuritis) and various inflammations — such as simple or phlyctenular 
conjunctivitis, iritis, panophthalmitis, uveitis, and cataract — are very 
uncommon. In convalescence, mydriasis and paralysis of accommo- 
dation often result from exhaustion. Amaurosis, either functional or 
lasting, from disk-disease, has been observed, as well as retinal hemor- 
rhages, optic neuritis, choked disk, optic atrophy, orbital hemorrhage, 
and venous thrombosis. Uhtoft, in 253 cases of optic neuritis, found 
17 cases following typhoid. 

Involvement of the ear includes functional toxemic disturbance of 
hearing, abscess, and otitis media (2 to 14 per cent.). Otitis is less 
frequent than in scarlatina or measles. Mastoid disease and menin- 
gitis are very exceptional. 

7. Muscles, Thyroid Gland, and Bones. — The muscles anatomically 
are dry, of a smoked-meat appearance, and may be the seat of hemor- 
rhages, rupture, granulo-fatty and waxy degenerations, and abscess, 
due to Eberth's bacilli and pus cocci. Myositis may explain some 
cases of muscular tenderness with cramps. 

In the thyroid gland, a strumitis typhosa, with suppuration or re- 
gression, has been observed. It is due to the typhoid bacillus. Re- 
covery is the rule. 

Though bone disease was observed in 237 cases by Keen, it is much 
more frequent than the figures indicate. Periostitis is more common 
than bone disease proper. These complications are post-typhoid and 
are due to the typhoid bacillus (75 per cent.), or pus cocci (25 per cent.). 
They attack the tibia (38 per cent.), the ribs (13 per cent.), femur, 
ulna, temporal bones, etc., and occur chiefly in young individuals. 
"Their most striking features are chronicity, indolence, and a re- 
markable tendency to recurrence 5 ' (Osier). Osteomyelitis may re- 
semble syphilitic or tuberculous osteopathies. Typhoid bacilli have 
been found seven and ten years after typhoid in osteomyelitic fistulas. 
Longcope has found marrow changes which resemble lymphoid hyper- 
plasia, and Fraenkel isolated typhoid bacilli in the vertebral marrow 
in ordinary cases of typhoid. 

Arthritis may be typhoid or gonorrhoeal, rheumatic, septic, etc. 
Keen has noted eighty-four cases. It may be poly- or mono-articular, 
serous or purulent. The hip is most frequently affected. The ''ty- 
phoid spine," of Gibney, is characterized by pain, tenderness, and 
stiffness in the back. Local trouble, such as spondylitis (six recorded 
cases), or perispondylitis, is sometimes found, but the so-called typhoid 



30 THE SPECIFIC INFECTIONS 

spine is often caused by hysteria, which is known to follow various 
acute infections. The prognosis is good. 

8. Digestive Tract. — The upper lip is retracted and bleeds easily. 
Sordes of dried saliva, food, and epithelium, are observed on the teeth 
and gums. Though the tongue shows nothing absolutely character- 
istic, Leube and others attach special importance to its appearance. 
At first it is white on the dorsum, moist, flabby, and therefore indented 
by the teeth, and its edges are red. It may be moist throughout the 
disease. In the second week it becomes dry (from the fever, lack of 
saliva, and mouth-breathing), small and fissured; it bleeds, and a 
brown or even black coating replaces the white. In the third week 
or later, a triangular patch clears at the tip of the tongue. Typhoid 
bacilli are not uncommon on the tongue. Acute glossitis is a severe 
complication. Aphtha? are rare, but may occur throughout the diges- 
tive tract. 

Angina may usher in the disease, or, occurring in the first week, 
lead to a wrong diagnosis. The throat is swollen, granular, and eroded. 
The angina is usually of the ordinary type, but may be specific (Wagner 
and French), due to the typhoid bacillus. The phlegmonous type 
is very dangerous.. An angina cachectica of white plaques or epithe- 
lium and bacteria is occasionally observed. 

Parotitis, occurring in J to 1 per cent, of the cases, has become less 
frequent since special care of the mouth has lessened infection ascend- 
ing Steno's duct. It is usually one-sided, is due to the typhoid bacillus, 
or pyogenic cocci, and is usually seen on the fifteenth day. It indicates 
a poor prognosis, especially when due to metastasis, and may reach 
the skull, meninges, or brain. Two personal cases, caused by the 
typhoid bacillus, recovered. 

Specific typhoid lesions are rarely observed in the stomach, although 
Leube records an instance with hsematemesis. Early and severe epi- 
gastric pain rather contraindicates typhoid. Incipient nausea and 
vomiting are unusual, occurring mostly in women or children. If 
observed at the height of the disease these symptoms suggest menin- 
gitis, overfeeding, or perforation, and (in convalescence) dietary errors. 

Anorexia is observed at the onset and during the fastigium, though 
great hunger develops in convalescence. 

Ulceration of the oesophagus is very rare; the cicatrized ulcer may 
produce later stenosis (twelve cases were collected by J. E. Thomp- 
son, 1904). 

The liver in the early stages is anatomically hypersemic, large and 
firm; later its lobular markings become indistinct from cloudy swell- 
ing and fatty change. The organ is softer, and Wagner's lympho- 
mata (and some focal necrosis) occur. Clinically, some tenderness is 
not unusual and at times may lead to an incorrect diagnosis of liver 
abscess or cholecystitis. 

Icterus is very rare (0.5 per cent.), and its absence is of diagnostic 
value, as the duodenal catarrh common in other infections is usually 
absent. Icterus may occur from gall-stones, cholecystitis, abscess, and 



TYPHOID FEVER 31 

acute yellow atrophy. The author has but once seen icterus in typhoid 
fever. Single liver abscess is rare, as are suppurative pylephlebitis and 
suppurative cholangitis. Sheldon (1903) noted twelve cases of multiple 
liver abscess. 

Bernheim maintains that typhoid favors the formation of gall-stones. 
They may develop months, years, or decades later. 

Cholecystitis has been reported by Chiari and others; thirty cases 
with perforation are on record. Tenderness, pain, muscular rigidity, 
and enlarged gall-bladder, are found in most cases. Typhoid bacilli 
are found in the gall-bladder in nearly all autopsies, although seldom 
having produced symptoms, and are held to be the main cause of re- 
infections. They may also invade the bile tracts without producing 
or following typhoid. The bacilli in the biliary tract more probably 
occur from hsematogenous than ascending infection. 

Bretonneau first noted specific changes in the intestines: (a) Hyper- 
emia, catarrh, and beginning medullary infiltration in the lymphoid 
structures during the first week, most changes being observed in the 
lower ileum, whence the name ileo-typhoid. (b) Medullary infiltra- 
tion or hyperplasia, during the second week, occurring first in Peyer's 
patches, and then in the follicles. The patches are oval and parallel 
with the long axis of the gut; they lie opposite to the mesenteric 
attachment, are 3 to 5 (8) millimeters high, and are at first red, then 
paler from compression of the blood-vessels. The infiltration is hard 
or soft. It may be uneven and reach beyond the plaque. The soli- 
tary follicles, even to the sigmoid flexure (colotyphoid), may be prin- 
cipally enlarged. These changes are not absolutely distinctive of 
typhoid, but are more significant in adults than in children, in whom 
they are frequent in digestive diseases, the exanthemata, and diph- 
theria. Mallory believes that the lymphoid swelling is wholly ex- 
plained by the proliferation of the endothelial cells of the vessels to 
act as phagocytes; when they degenerate, fibrinous thrombi develop. 
Medullary infiltration need not advance to ulceration. Regression 
may occur and the lymph-cells degenerate and disappear. The lym- 
phatic structures may then assume a reticulated, or " shaven beard," 
appearance, (c) Ulceration occurs in the third week, from anaemic 
necrosis, slough formation, and exfoliation of small particles. The 
ulcers thus formed by the typhoid bacilli are usually easily seen with- 
out opening the gut. They have an irregular, oval outline, sharp, 
steep, often undermined edges, with a red floor generally composed 
of the muscular coat and often extending deeper than the eschar. 
The lower ileum is most affected and may present almost no normal 
surface in extreme cases. The solitary follicles, both in the large and 
small gut, ulcerate at their apices. Baer has studied the localization 
of the typhoid ulcer and states that it may occur in any part of the 
digestive tract except the mouth. The pharynx is affected in 2 per 
cent, of the cases, the oesophagus in 4 per cent., the stomach in 2 per 
cent.; 97 per cent, of the ulcers develop in the small intestine, S9 per 
cent, in the ileum, and 2 per cent, in the appendix; 33 per cent, in the 



32 THE SPECIFIC INFECTIONS 

large intestine, — and there only, in 6 per cent, (d) Cicatrization occurs 
by formation of granulation tissue and growth inward of the epithe- 
lium. The patch is depressed and slightly pigmented. The typhoid 
cicatrix does not narrow the intestinal lumen. 

There may be few or no anatomical changes in the intestine. This 
is analogous to diphtheria without membrane, and the exanthemata 
without eruption. Slight bowel lesions are usually present in most 
of the cases reported "without intestinal lesions." 

The mesenteric glands are swollen, contain typhoid bacilli, are al- 
tered like the intestinal lymphatics, and may be palpable. The swell- 
ing occurs mostly in the second week. The swollen glands may 
regress, soften, become tuberculous, or suppurate, sometimes causing 
peritonitis, or simulating perforation, as in a case of the author's. 
Only six cases are recorded of suppuration in the mesenteric glands; 
Le Conte reports a recovery after operation. Other lymph-glands 
may be similarly involved. 

No parallelism exists between the frequency, constancy, or severity, 
of the clinical symptoms, and the degree of anatomical involvement; 
e. g., in ambulant cases there may be perforation or hemorrhage, or 
typical lethal cases may occur without intestinal change. 

Meteorism is rather less common than usually described. It occurs 
mostly in the duodenum or jejunum above the ulceration, or some- 
times involves the colon. It is less frequent and less intense with 
early treatment and careful dieting. If much tympany develops under 
these circumstances, the prognosis is poor, since meteorism is due to 
toxemic paresis of the intestinal musculature rather than to local 
ulceration, catarrh, or serous infiltration. The heart and lungs may 
be crowded upward and dyspnoea result. It may occur with hemor- 
rhage or perforation. 

A thickened ileum may be palpated. Abdominal tenderness and 
pain occurred in 60 per cent, of Osier's series, where particular atten- 
tion was paid to these points. They are due to: (a) local bowel con- 
ditions, as gas, constipation, inflammation in the ileocecal region, or 
perforative and peritonitic complications; (b) to splenic or hepatic 
tumefactions; (c) pleurisy, distended bladder, phlebitis, etc.; (d) 
muscle changes or cutaneous hyperesthesia, so frequently observed 
in fever of any variety. 

Typhoid appendicitis may simulate ordinary appendicitis, which is 
differentiated only by the blood -count, sero-reaction, or, most surely, 
by the clinical evolution; e. g., the fever spots, etc., when due to 
typhoid, precede local pain and tenderness. Gurgling has no diag- 
nostic value whatever in typhoid, although it occurs in most cases. 

The stools present no pathognomonic chemical nor physical char- 
acteristics other than the bacillus typhosus, which is often absent 
during the first week, and also in the later course. The dejecta are 
thin, offensive, pea-soup-like, alkaline, and resemble the contents of 
the small intestine (Addison). Because the feces are poor in mucus, 
two layers form on standing, an upper cloudy, and a lower, yellow- 



TYPHOID FEVER 



33 



gray, granular and flocculent layer. The solids are 4 per cent. The 
stools contain red corpuscles and triple phosphates, the latter more 
abundantly than in any other disease. Shreds or sloughs may also 
be found. 

Diarrhoea in the febrile stage occurs in 25 to 33 per cent, of the 
cases, although some state that it is observed in most patients. Three 
to six stools are the average. If this is exceeded, the type of the 
disease is severe; prodromal diarrhoea rarely occurs. Diarrhoea is a 
measure of the degree of toxaemia or of colonic involvement, and is 
not a result of ulceration of the small intestine. 

Hemorrhage is seen in 4 to 6 per cent, of the cases. In point of 
time it is usually late, though some assert that in 30 per cent, it occurs 
in the first two weeks. It is less frequent in relapses and in children 
(1 per cent.). Ulceration into the muscularis is its chief cause. Ooz- 
ing, from simple hyperemia, bleeding in the hemorrhagic forms (blood 
dissolution), and in patients inheriting the bleeding tendency, are 
exceptional. Bleeding is more common in ambulatory, delirious, and 
carelessly fed patients. There may be no symptoms if the hemorrhage 
is small (occult hemorrhage); but if it be large, acute anaemia sud- 
denly develops, with collapse, which is evidenced by a fast pulse, 
lowered temperature, and pallid skin. The intellect often clears, the 









Fig. 4. 








PU .SE TEMP. 
104 














ISO 

103 


y\W 








S\ 




110 

102 


/v 






/ 

/ 


\ 


aA^ 


100 

101 




/\ 


\ ^** s 




A/ 7 




90 

100 




'V' N 


-''M 


A A 


r 




80 

99 








\r 


/ 




ro 








\ 














V 










2ND WEEK 


FOL 


R CCFIOUS 
HAEMORRHAGE 


STC 
S TR/ 


IOLS WITHOUT 
,CES OF BLOOD 



Typhoid-fever curve, with fall of temperature (solid line) after hemorrhage and rise of pulse 
(broken line). Note crossing of curves at A. 

spleen becomes smaller, and fresh blood, or, later, black, tar-like move- 
ments, are voided (manifest hemorrhage). The abdomen is often 
distended. There may be dulness on percussion from blood retained 
in the bowel, if the peristalsis is weak and the hemorrhage is very 
profuse. In two rapidly fatal cases the entire abdomen became flat 
and one and two pints of blood were vomited. Confusion with bleed- 
ing piles and bismuth stools is possible. The average number of 
hemorrhages is four. 

Some patients improve at once after hemorrhage, as was remarked 



34 THE SPECIFIC INFECTIONS 

at an early date by Graves and Trousseau; yet 20 to 50 percent, die. 
Large blood-clots are ominous, indicating erosion of a large artery. 
Hemorrhage may cause death within an hour (Trousseau, Leymarie). 
Perforation occurs mostly at the time of eschar-formation, at the 
end of the second, or in the third week; but it may also occur later, — 
in the third to fourth week (50 per cent., Fitz); or from the third to 
the fifth week (Leube). Scott found that 92 per cent, occurred be- 
tween the second and fifth weeks. It develops in 9 to 12 per cent, of 
fatal cases and in 3 per cent, of all cases, but it very rarely occurs in 
children. Scott's figures, including 9,713 English and American cases, 
show perforation in one-third of all fatal cases. Perforation is usually 
low in the ileum (81 per cent.) ; or in the colon or sigmoid (12 per cent.) ; 
in the appendix (3 per cent.); in Meckel's diverticulum (2.4 per cent.); 
or in the jejunum (1.2 per cent.). The percentages are from Fitz's 
figures. In 83 per cent, of the cases but one perforation is found, 
though several may occur, twenty-five being once observed in one 
patient. It is promoted primarily by deep ulceration, and secondarily 
by severe infections, movement, strains, coughing, constipation, gas, 
or solid diet, which increases peristalsis. It is claimed that 75 per 
cent, of the cases of perforation occur in severe infections. Three 
types are encountered: (1) Least frequently, undiscovered latent per- 
foration; the typhoid state masks the perforation, which affords an 
unpleasant postmortem surprise. (2) More frequently, cases with 
gradual onset, and therefore ambiguous symptoms. (3) Most fre- 
quently, cases with sudden symptoms and more or less clear diag- 
nosis. The symptoms of perforation are: (a) Pain (in 75 per cent, 
of the cases) due to the perforation itself, usually localized in the 
hypogastrium or right lower quadrant of the abdomen and followed 
later by the pains of peritonitis. In 70 per cent., the pain was sudden 
and severe; in 20 per cent., gradual in onset. ; and in 10 per cent, it was 
absent, (b) Tenderness on palpation (75 per cent.), evidenced by 
the board-like rigidity of the abdominal muscles, (c) Limitation of 
the respiratory movements of the abdomen, due to pain and tender- 
ness, (d) Vomiting of gastric contents or faecal matter, (e) Intestinal 
obstruction. (/) Abdominal distention, appearing possibly for the 
first time — in which event its significance is enhanced — or increasing, 
if already present. There are cases in which the abdomen is flat or 
even retracted; in one typhoid patient, seen first in a dying condition, 
the scaphoid abdomen contained three pints of pus. Abdominal dis- 
tention crowds upward the diaphragm, heart, and lungs, and causes 
hurried breathing, (g) Disappearance of the flatness of the liver by 
reason of free gas in the peritoneum. This is most significant if the 
abdomen was not previously distended. Perihepatic adhesions natur- 
ally prevent obliteration of the liver dulness, and it must always be 
remembered that a gas-distended colon may overlie the liver; and 
that in some cases the colon normally overlaps the liver, (h) Other 
occasional abdominal findings are flatness in the flanks, caused by 
fluid; the Beatty-Bright friction-rub; absence of paristalsis; rectal 



TYPHOID FEVER 35 

or vesical pain or tenderness, (i) Marked leukocytosis is not always 
found, and special emphasis on its absence is most misleading, as 
the leukocytes are occasionally decreased, (j) Sudden fall of tempera- 
ture, rapid rise in pulse-rate, and other signs of shock, may occur at the 
time of perforation, though less frequently than the usual descrip- 
tions indicate. The writer has seen cases in which the pulse-rate did 
not increase. Dieulafoy mentions a case, successfully operated for 
perforation, in which two later perforations resulted fatally. The 
sudden clearing of the patient's intellect may deceive the inexperienced 
physician. In the advancing generalized peritonitis, the fever, if it 
has fallen, rises; the pulse becomes rapid, small, and thready; the 
skin clammy and dusky, and the features pinched (facies Hippocra- 
tica). Hiccough is common. The peritonitis rarely remains local. In 
six of the author's cases, the local abscess was ruptured later. Ninety- 
eight per cent, of the unoperated cases die. 

Peritonitis occurs frequently in ambulatory cases, from rupture of 
the bowel, gall-bladder, spleen, lymph-glands; occasionally from post- 
typhoid appendicitis or without rupture of any organ or tissue. It 
is found in 2 per cent, of fatal cases. 

9. The Respiratory Tract. — This is the seat of frequent and mani- 
fold symptoms and complications. 

(a) The Nose. — The nose is dry. Epistaxis occurs in 7 to 20 per cent, 
of the cases, usually early, and in young subjects; it is often profuse, 
sometimes dangerous, but rarely lethal. Croup and diphtheria are 
rare; coryza is very rare. The author has seen two cases begin with 
profuse coryza. 

(b) Larynx. — Catarrh is common. Decubitus, with erosions of the 
swollen hyperplastic lymph-follicles (like the intestinal changes), occur 
in the posterior wall, followed often by oedema glottitis. These bed- 
sores are seen at the height of the fever; occur rarely in children; and 
are found in 5 to 20 per cent, of the lethal cases. Perichondritis and 
necrosis are attended by pain, aphonia, stenosis, mediastinitis, cervical 
cellulitis, and diffuse emphysema. Tracheotomy may be indicated. 
The author has seen but three cases of perichondritis. Dupuy (1903) 
collected 255 cases of perichondritis and submucous laryngitis, and 
believes they explain 3 to 10 per cent, of typhoid fatalities. Without 
operation, the mortality is 98 per cent. Laryngeal neuritis, with cord 
paralysis, follows typhoid in 25 per cent, of the cases. 

(c) Air Tubes. — A dry catarrh of the trachea and bronchi is al- 
most invariable, while ulceration (in one-third of 1 per cent.) or fibrinous 
inflammation is rare. Rales, retrosternal dryness, rawness, and pain, 
are present in the bronchitis of typhoid. At autopsy the bronchial 
glands are often swollen, and Eberth's bacillus is sometimes found. 
Bronchiolitis is regular and specific. It is found everywhere in the 
lungs, but especially in the lower lobes, and (rarely) wholly above and 
in front. Coughing is not invariable but its presence in early typhoid 
is of value in differentiation from simple intestinal catarrh. The out- 
look is less favorable when severe and early coughing occurs 



36 THE SPECIFIC INFECTIONS 

(d) Lungs. — Hypostasis, from a dorsal decubitus and weak heart, 
is often relieved by change of posture. It is very common, and occurs 
in the first half of the disease, or at its height, mostly in weak adults 
and in cases of severe infection. Lesser degrees of hypostasis may be 
overlooked. The percussion-note is tympanitic or dull. The fremitus 
is increased, if the patient can talk, or decreased from stagnation of 
secretions. The breathing, and especially the expiration, is distant 
(or sometimes bronchial). Rales, moist, crepitant, and subcrepitant, 
are heard. 

Lobar pneumonia may, in rare instances, dominate the early clinical 
picture (pneumo-typhoid) and may be of two types. The first type, 
(a), is due to Eberth's bacillus. The course is that of an initial pneu- 
monia, which does not end typically, but shows later a typhoid tem- 
perature, rose spots, Widal reaction, etc. These cases are naturally 
confusing, especially in their incipiency, and the typhoid is more apt 
to be overlooked than in the next type, (6) in which the pneumonia, 
usually seen at the height (third week) of the disease, is a true com- 
plication, due to the pneumococcus, though sometimes due to the 
colon bacillus and streptococcus, especially in sepsis. The pneumonic 
symptoms are variable, atypical (as in most secondary pneumonias), 
often without chill, with a slower course, and often with lysis, or, less 
often, with such complications as abscess or gangrene. More than one- 
half of these cases die. Lobular pneumonia, from inhalation, pus- 
cocci, and Eberth's bacillus, is a true complication. Abscess follows 
pneumonia or sepsis; it occurs in 0.7 per cent, of the fatal cases. 
Infarct occurs in 6 per cent, of typhoid fatalities. Marantic thrombi 
from the leg may reach the lungs by way of the right heart. This is 
indicated by haemoptysis, chill, temperature, pain, etc. Gangrene (1 to 
2 per cent, of typhoid autopsies) occurs more often than abscess, is 
seen late in the disease, and is usually metapneumonic, but may be 
caused by perichondritis or aspiration of food. 

(e) Pleura. : — Serofibrinous pleurisy is usually rare unless the lungs 
are diseased. Sears observed 18 cases in 1,065 typhoid patients, and 
Leube has seen several with pleural friction. Postmortem statistics 
show it in 6 to 8 per cent. It is most common as empyema in conval- 
escence, and is due oftenest to Eberth's bacillus. In 1903, fifty-five cases 
of pleurisy were collected in which the typhoid bacillus was found. 
Pneumothorax and haemoptysis are very uncommon. 

(/) Tuberculosis. — Old latent tuberculosis may be aroused, usually 
late in the disease. It is associated sometimes with pneumococcus 
infection. Other forms, such as acute caseous pneumonia, subacute 
tuberculous peribronchitis with a few bacilli, fever, emphysema and 
aggravation of the bronchial symptoms, and occasionally miliary tuber- 
culosis, may occur. 

10. Genito-Urinary Tract. — The following conditions may be found: 
(a) The urine is febrile; as water is retained in fever, the urine 
becomes decreased, acid, concentrated, with a specific gravity of 1,030 
or more. Uric acid, urea, and toxins, are increased; the chlorides, de- 



TYPHOID FEVER 37 

creased. Typhoid bacilli are present in 25 to 50 per cent, of the cases, 
or even 80 per cent., according to other statistics. The bacilli may give 
the urine a glistening appearance. Bacilli may persist from four 
months to several years after recovery. In convalescence, the urine 
is increased, is neutral in reaction, and has a lower specific gravity. 
Sometimes polyuria may occur during the fever, (b) Serum albumin, 
globulin, and rarely peptones, are found in febrile albuminuria. Serum 
albumin is found, in quantities varying from traces to considerable 
amounts, in 15 to 20 per cent. of the cases; cylindruria is approximately 
half as frequent. The prognosis is three times as unfavorable when 
albumin is found. It appears from the seventh to the tenth day, is 
frequent in the third week, and its average duration is twelve days. 
It corresponds anatomically to parenchymatous and fatty degenera- 
tion of the kidneys, (c) Nephritis in typhoid is of the acute par- 
enchymatous type, with the interstitium of the organ but little involved. 
It is often hemorrhagic, and occurs usually in the first three weeks 
but occasionally in convalescence. It is found in 1 per cent, of the 
cases, mostly in men, rarely in children. Nephritis makes the prog- 
nosis less favorable, as it indicates a more severe infection, from 
which 50 per cent, of the cases die. Uraemia and suppression of urine 
are rare. If not fatal, nephritis usually clears up entirely and rarely 
remains in chronic form. Early and marked renal symptoms con- 
stitute the nephrotyphoid of French writers. Sepsis may produce 
septic nephritis and abscesses. Miliary typhoid abscesses in the kid- 
ney may keep up the bacilluria. Lymph-nodes are found in some 
cases, as in the liver (Wagner), (d) The urine of typhoid exhibits 
the diazo reaction of Ehrlich (1882). Two standard solutions are 
kept in separate bottles: No.T — -a 5-per-cent. solution of hydro- 
chloric acid saturated with sulphanilic acid, which should be fresh; 
No. 2 — one-half-of-1-per-cent. solution of sodium nitrite. To make the 
test, forty parts of No. 1 and one part of No. 2 are mixed, producing 
diazo-benzine-sulphonic acid. Equal parts of this mixed solution and 
urine are thoroughly shaken; one part of ammonium hydrate is then 
allowed to flow carefully down the side of the tube to stand above the 
urine mixture. At the junction of the two fluids, a dark garnet or 
cherry-red ring will form in typhoid urine, and in normal urine only 
a brown ring. The pink color of positive tests is also imparted to 
the foam on shaking, or in marked dilutions gives a rose-red hue. 
Osier found it in 69 per cent. The author has found it in 98 per cent. 
of his cases. It occurs in the early stages of the disease, also at the 
acme and during relapses. It is a valuable sign, though of secondary 
rank. Since it is found in numerous other acute and chronic condi- 
tions, it has no differential or pathognomonic value. Its absence, to- 
gether with the absence of other findings, contraindicates a florid 
typhoid. (e) Cystitis and pyelitis occur during the disease or in 
convalescence, and are due chiefly to pus organisms, or typhoid or 
colon bacilli. Simple retention of urine is not uncommon. Uro- 
bilinuria (Tissier) and indicanuria occur, but neither is proportion- 



38 THE SPECIFIC INFECTIONS 

ate to the severity of the disease. Hemoglobinuria is quite rare. (/) 
The genitalia are more often implicated in women than in men. Men- 
struation is disturbed. It often appears early in the onset of typhoid, 
and is suppressed in 60 per cent, of the cases. In some instances 
hasmatocele or hsematometra may develop. Endometritis, either croup- 
ous or diphtheritic, vaginal erosions, ulcers, inflammation, or gangrene 
and mastitis, are rare complications. Pregnancy is of grave import, 
the outlook being worse in its later stages than in the earlier (e. g., 
eight to ten weeks). It is most dangerous at the acme of the fever, 
abortion and premature delivery being very frequent (65 per cent, 
of the cases). The maternal mortality is increased at least twofold. 
Blumer and Dobbin have reported puerperal infection from the typhoid 
bacillus. Orchitis usually develops late, or in convalescence. It occurs 
with chills and fever. The patient almost always recovers in ten to 
fourteen days, although suppuration and atrophy have occurred — 
fifty-three cases were collated by Kinnicutt. It is frequently associated 
with urethritis. Emissions are common in convalescence. 

Anomalous Courses. — According to Curschmann, the following 
anomalous courses are distinguished: 

1. Malignant. — The malignant, hyperpyretic or foudroyant form is 
rare. It is severe even in the earliest stages. The temperature rises 
rapidly and there may be hyperpyrexia. The pulse is soft, weak, and 
rapid. The status typhosus is profound. Meteorism, diarrhoea, and al- 
buminuria, are present, and death from deep intoxication usually occurs. 

2. The Slow Severe Form. — The slow severe form lasts from four 
weeks to four months. The fever is often remittent with frequent 
exacerbations. Defervescence may occur or death intervene, mar- 
asmus alone being found at autopsy. The severe types of typhoid 
have grown rarer, even during the last decade. 

3. Typhus Abortivus. — Typhus levissimus, typhulus, typhoidette of 
Brouardel, exhibits a short and mild course, temperature with a 
short initial stage, or often a crisis, lasting six to twenty days. Bron- 
chitis is frequent, the spleen enlargement is constant, and meteorism, 
diarrhoea, roseolas, hemorrhage, or perforation, are rare. Relapses are, 
however, more frequent. 

4. Typhus ambulatorius (of the German, or latent typhoid of French 
writers — walking typhoid), occurs in adults, especially in men, who 
often endure it by the help of alcohol. Some malaise may exist. There 
are two types: (a) the lighter and atypical, and (b) the usual course, 
very often ending in hemorrhage, perforation, etc. The temperature is 
often not marked, but is usually less at night than during the diurnal 
activity. The pulse is faster because of exertion. The spleen is often 
enlarged, and the roseolas are frequent. 

5. Typhus afebrilis (Liebermeister and Gerhardt) is most often met 
with in family practice. It may assume the ambulatory form; and 
is diagnosticated by exclusion and by the pulse, spleen, roseolas, diazo 
reaction, Widal test, etc. Atypical cases have apparently increased 
ir recent years. 



TYPHOID FEVER 39 

6. The hemorrhagic form is characterized by nasal, subcutaneous, 
and particularly intestinal hemorrhage, constituting the blood dissolu- 
tion of the older writers. It occurs especially in children and alco- 
holics, and constitutes less than one-tenth of 1 per cent, of typhoid 
cases. The prognosis is usually but not invariably bad. The four 
cases which the author has seen occurred in 1900, in St. Luke's Hos- 
pital, where a severe house-epidemic prevailed. 

7. Visceral Forms. — The so-called visceral forms should seldom cause 
confusion, if watched with care. They include the gastric or bilious 
types, nervous fever, meningo-typhoid, cerebro-typhoid (mania, psy- 
choses), laryngo- or tonsillo-typhoid, nephro-typhoid, pneumo-typhoid 
with pneumococcus mixed infection or Eberth's bacillus, (Lepine, 
Chantemesse, Widal,) which is pneumo-typhoid in the narrowest 
sense. 

8. In children but few cases occur in hospitals. The temperature 
course is shorter and milder than in adults. The younger the patient, 
the less is the degree of fever. It may begin with a chill. It is often 
remittent, the "infantile remittent fever" of Abercrombie being really 
typhoid. Epistaxis is less common. The pulse in children is faster, 
and more often irregular, than in adults; though after the twelfth (fifth, 
Filatow) year, it is equally slow. A weak and irregular pulse is very 
rare, and a fast, irregular pulse generally indicates meningitis. Opin- 
ions differ as to the frequency of roseolas; they vary with the epidemic, 
but it is probable that they occur as often in children as in adults. They 
may be fewer and may appear later, but in some cases are abundant 
and confluent (in children between the fifth and tenth year). Bed- 
sores are very rare, but noma is more frequent than in adults. The 
nervous system is generally less frequently involved in children, though 
if the infection is severe, convulsions, irregular pupils, rigidity of the 
neck, headache, etc., may occur. (See Typhoid State.) Neuralgias and 
psychoses are rare. The frequency of aphasia has not yet been ex- 
plained. Bronchitis occurs as often as in adults, but atelectasis, 
hypostasis, and lobular pneumonia are more frequent. Children exhibit 
less meteorism and hemorrhage (1 per cent.), and much less frequent 
perforation. There are fewer anatomical changes. Splenic enlarge- 
ment is less frequently palpable (in 50 percent.), and occurs somewhat 
later. Initial vomiting, pain, and perhaps diarrhoea, are more frequent. 
Albuminuria and nephritis are relatively rare. Griffith and Ostheimer 
have assembled 394 cases in children, of which 325 are beyond doubt. 
Of these, 139 occurred under one year, 187 in the second, and 6S 
between two and two and one-half years. The mortality under one 
year (v. i.) was 73 per cent., and of the entire group, 50 per cent. Ty- 
phoid is rare in the first two years of life. It is sometimes overlooked, 
being very atypical. The course is short. Bronchitis, splenic tumor, 
and roseolas, are infrequent. If the disease is severe, a very high tem- 
perature, meningeal symptoms, and initial vomiting occur, and also 
50 per cent, mortality caused by toxaemia, pneumonia, perforation, or 
ulceration of the larynx. 



40 



THE SPECIFIC INFECTIONS 



9. In the aged typhoid is infrequent, especially after the fortieth 
year. In such cases the fever is lower, atypical, and often absent. 
The pulse is faster, irregular, and without dicrotism. There is greater 
lung congestion owing to weakness of the right heart, and lung com- 
plications are more frequent. The nervous symptoms are dominant, 
often occurring with great depression. Roseolse are fewer and bed- 
sores are more frequent. The spleen is much less often enlarged 
because of old infarcts, induration, and a thicker capsule. Tympany 
and hemorrhage occur more often. Convalescence is naturally slower. 
In 1903, the author had under his care, in Wesley Hospital, a woman, 
aged fifty-seven, and her mother, aged seventy-two, both with typhoid, 
ending in recovery. 

Relapses and Exacerbations.— Relapses and exacerbations differ 
in degree only. Their explanation is still obscure, reinfection from the 
gall-bladder, spleen, glands, and the bones, having been advanced as 
causes. In the complete relapse the temperature falls to normal, or 
nearly to normal, for five days on the average, and then fever and other 
signs of typhoid reappear. It occurs in 6 to 12 per cent, of the cases, 
and vary with the epidemic, sometimes occurring in as many as 35 
per cent. Relapses are more common in young (in one-sixth of 
Henoch's cases) than in old subjects. They are more likely to occur 
(a) in light or moderately severe cases (75 per cent.) than in severe ones 
(25 percent.); (b) when the splenic tumor does not disappear (Ger- 
hardt; (here the question may, of course, arise whether or not the 
spleen was enlarged from some previous disease, such as malaria;) (c) 
when the temperature in convalescence does not become subnormal 
(Curschmann); or (d) when the pulse is variable and rapid while the 
patient is quiet (Curschmann). 



Fig. 5. 




HlCHItVER RLk-ISSION E. X-iCE.,\5*T IOS LYSIS (fH.i»;A 

Showing remission, exacerbation, lysis, and relapse. 



After an average defervescence of five days, the fever runs the same 
course as in the first. attack, though it is shorter by ten days (Murchi- 
son). The pulse is faster (110 to 130 in women, children, and weak 
men), labile, and less dicrotic. There are less roseolse (absent in 27 
per cent.), nervous symptoms, respiratory symptoms, hemorrhage 



PLATE I 



FIO. 1 




Bouillon Culture of Typhoid Bacilli before the Addition of Diluted 
Typhoid Serum. X SOO. ( After Cabot.) Serum diagnosis. 



FIG. 2. 




The Same, Five Minutes after the Addition of Typhoid Serum (dilution 
1 to lO), showing Typical Clump Reaction. \ 400. iCabotJ 



TYPHOID FEVER 41 

(4 per cent.), and perforation (0.7 per cent.), whence, as a rule, the 
prognosis is relatively good. The duration of the relapse is six to fifteen 
(even twenty-one days), and there are seldom more than two, — three or 
four being very rare. The author has seen five relapses, covering, with 
the original attack, as many months. It is said that they may be afeb- 
rile, with a return of the roseola?, spleen, etc. Relapses should not be 
confused with Biermer's "after fever," due to inanition or possible 
sepsis. Recrudescences are renewals of the fever after it has lessened, 
but not entirely subsided. In 50 per cent, of the cases recrudescence 
is followed by more severe symptoms. 

Convalescence. — Convalescence requires fourteen to twenty-one 
days, but its duration is variable, and it is not certainly established till 
subnormal temperature, at least in moderate or severe infections, is 
observed. The pulse tends to run high on exertion or excitement. 
Anaemia, emaciation, oedema, phlebitis, gall-stones (formed by Eberth's 
bacillus), tuberculosis, neurasthenia, psychoses, bone, muscle, and 
other complications, may occur. If the appetite is poor in convales- 
cence, complications are to be expected. 

Diagnosis. — General Rules.— 1. The bacteriological diagnosis is not 
usually practicable, for the colon bacillus confuses the inexperienced 
physician in the examination of the urine and fseces. Splenic puncture 
is never indicated, though positive in 95 per cent, of cases tested. The 
bacilli may be found in the blood in nearly all cases, and practically 
always in the roseola?. 

2. Observe long and carefully. Say that "a diagnosis is impossible 
in the first few days." 

3. No single sign is absolutely diagnostic, except bacilli in the blood, 
etc., and the characteristic Widal reaction. 

4. Diagnosticate (a) from positive findings, and (b) by careful 
exclusion. 

5. The "typhoid state" only indicates some toxaemia, not necessarily 
typhoid. 

6. In doubtful cases remember the great statistical frequency of 
typhoid. 

7. Remember its manifold forms; e. g., pneumo-typhoid, etc. 

8. Be on the safe side in light, ambulatory, or abortive cases as to the 
diagnosis and the still more important matter of treatment. 

The Cardinal Signs. — These are: (a) The Widal test; (b) bacilli in 
the blood, in the urine, in the roseola?, etc.; (c) the roseola? ; (d) the 
slow pulse; (e) the fever-curve; and (/) the splenic tumor. 

(a) The sero-test, successful in 95 to 97 per cent, of cases, is important. 
As stated above, its absence does not exclude typhoid. 

(b) The bacilli in the blood are found in practically all cases. 

(c) The eruption has a diagnostic value in its location, occurrence 
in crops, time of appearance, and short duration. 

(d) The slow pulse, and to a much less extent its dicrotism, are 
suggestive. It is rarely to be confused with the slow pulse of tubercu-. 
lous meningitis. 



42 THE SPECIFIC INFECTIONS 

(e) The fever-curve shows a gradual, step-like onset, continuous 
fastigium, steep curves in the breaking stage, and subnormal register 
in established convalescence. 

(/) While the splenic tumor occurs in many other infections, it is 
per se suggestive after the first week. 

Secondary Signs. — These are, in order of importance, the typhoid 
tongue, the stools, bronchitis (especially after the first week), the 
typhoid state, leukopenia, intestinal symptoms and complications, and 
the diazo reaction. 

Symptoms contraindicating typhoid are, according to Leube, coryza, 
early vomiting and sweating, herpes, endocarditis, retraction of 
the abdomen, persistent constipation, and constant failure of the 
diazo test. To these may be added leukocytosis (unless some complica- 
tion has occurred), icterus, and rigors. All of the above-mentioned 
symptoms may, exceptionally, complicate typhoid. 

Differential Diagnosis. — Differentiation from acute miliary tubercu- 
losis may be most difficult. In both diseases protracted fever, splenic 
tumor, brain symptoms, bronchitis and bronchopneumonia, rapid 
pulse, etc., maybe observed, and miliary tuberculosis may develop from 
typhoid (Birsch-Hirschfeld, and in two personal observations). Ty- 
phoid may be complicated with septicaemia, very rarely with malaria 
in this climate, or with meningitis. The table on pages 44 and 45 
illustrates the differential diagnosis of the diseases most likely to be 
confused with typhoid. 

Exanthematous typhus (q. v.) and recurrent fever (q. v.) are easily 
distinguished. The exanthematous diseases, such as scarlatina and 
measles, are rarely confused, except, perhaps, in the initial stage. A 
most extensive eruption of roseolas resembling measles is easily dis- 
tinguished by the course, temperature curve, and catarrhal symptoms. 

Fibrinous pneumonia rarely resembles typhoid, or still more rarely 
occurs with typhoid in its earliest stages. Though typhoid may begin 
with severe bronchitis or pneumonic symptoms, doubt usually exists only 
during the first few days. The pneumonic type of typhoid, caused by 
the localization of the typhoid bacilli in the lungs, is most uncommon. 
The intestinal symptoms and cardinal findings of typhoid usually 
appear after a few days or one week, and all doubt is then dispelled. 
Pneumonia may undoubtedly occur without local findings, and yet the 
diagnosis of central pneumonia should rarely be made, as it is usually 
incorrect. Sudden onset with chill, pain in the side, sudden rise of 
pulse and temperature, rapid respiration, bloody, viscid sputum, 
herpes, icterus, marked leukocytosis, and usually signs of local 
infiltration or a tympanitic note over one lobe and a few crepi- 
tant rales, followed later by some typical pneumonic infiltration as 
the disease advances from within toward the periphery of the lung, 
establish the diagnosis of pneumonia, usually on the second or third 
day. • 

Intestinal anthrax is also accompanied by fever, splenic tumor, and 
nervous symptoms. Hemorrhagic vesicles in the mouth, vomiting, 



TYPHOID FEVER 43 

colic, hemorrhage from the intestines and kidney, cyanosis and dyspnoea, 
are suggestive, and the detection of the anthrax bacillus in the blood, 
urine, stools, or sputum, and the results of inoculation, establish the 
diagnosis. 

Febrile gastritis may simulate typhoid, but the fever is usually low or 
irregular, and is more often absent than present. Marked early gastric 
symptoms are not common in typhoid. Febrile enteritis is usually 
characterized by much mucus in the stools. Though typhoid may 
occur with an old enterocolitis, the layers of the typhoid stool result 
from the lack of mucus. Splenic tumor has been observed occasionally 
in enteritis, but it is most uncommon. The fever in enteritis is lower 
or more irregular, than in typhoid; and the bronchitis, the slow pulse, 
and the other cardinal signs of typhoid, are absent. Cases of typhoid 
developing suddenly may be, at first, confused with grippe, diphtheria, 
or other diseases. Febrile syphilis should seldom cause diagnostic 
trouble. 

Paratyphoid (paracolon infection) is due to a bacillus differing from 
the bacillus of typhoid and of dysentery, and from the Bacillus coli, 
and resembling the Bacillus enteritis, Bacillus psittacosis, etc., yet 
different from all of these. Two types of organisms are recognized — 
one producing a permanent and the other a transient reaction in milk. 
Infection may occur from milk, water, and tainted meat. The bacilli 
are found in the stools, blood, roseolse, and urine, and agglutinate in 
higher dilutions (1 to 1,000 or 2,000) than the typhoid bacilli. The first 
cases were reported by Schottmueller, in 1900. In paratyphoid the 
temperature is more irregular than in typhoid, shows greater remissions, 
and may end with a crisis. The pulse is slow and dicrotic. 
Roseolas are often present (80 per cent, of the cases), the spleen is 
usually enlarged, and no leukocytosis is observed. Prodromal catarrhs, 
diarrhoea, cervical adenitis, oedema of the lids, vomiting, epigastric 
pain, herpes, myositis, arthritis, pleurisy, endocarditis, and meningitis, 
are more common than in typhoid. The diazo test gives the character- 
istic reaction in 30 to 60 per cent, of the cases. The clinical course 
covers two weeks (twelve to eighty-four days). Relapses are common. 
The infection is usually mild, sometimes severe, and rarely fatal (3.6 per 
cent J. Ulceration of the intestinal lymph-structures is absent in the 
fatal cases, though other necroses occur, thus explaining the occasional 
hemorrhage (5 per cent.). Pneumonia and perforation are unknown. 
The disease is comparatively rare. The blood does not respond to the 
Widal test nor are typhoid-bacilli found, but otherwise it is indis- 
tinguishable from typhoid. Grunberg and Roily hold that the Widal 
reaction is less a specific than a group reaction, as they found agglutina- 
tion in the paratyphoid group by typhoid serum. This does not imply, 
however, that failure to respond to the Widal test excludes typhoid 
(Johnstone). A mixed infection with typhoid may occur. 

The paracolon organism (recognized by Widal, in 1897) presents a 
serum reaction peculiar to itself when brought in contact with the 
blood of a patient suffering from the disease. 



44 



THE SPECIFIC INFECTIONS 



Pathognomonic Signs 



Pulse and 
Circulation 



Fever 



Splenic 
Enlarge- 
ment 



Blood 



Typhoid. 



Typhoid bacilli 
in the blood 
spleen (by 
puncture ), 
urine, roseolae, 
or stools. 
Widal test. 



Relatively slow di- 
crotic pulse early in 
the disease, espec- 
ially in men, and 
in not too severe 
infections. Endo- 
carditis and peri- 
carditis very rare. 



Typical rise, acme. 
d ef ervescence , 
and subnormal in 
convalec enc e. 
Remissions and in- 
termissions follow- 
ing continuous fe- 
ver speak for ty- 
phoid. Responds 
to hydrotherapy as 
a rule. Sometimes 
chills at onset or in 
course. 



V e r y f r e- Bacilli in blood, 
q u e n t; early; Widal test 
larger than later. No leuko- 
in miliary cytosis unless com- 
t u b e r c u- plications, but leu- 



1 o sis; ap 
pears in 

first week. 



kopenia. Poly- 
morphonuclears 
decreased. Late 
anaemia. 



Miliary Tubercle bacilli 
Tubercu- in the blood or 
losis. splenic pulp; 

tubercles in the 

choroid. 



Rapid, 120 or more 
high even during 
remissions: slowed 
in tuberculous men- 
ingitis and in the 
aged. Dicrotism 
uncommon. Some- 
times pericardial 
rub. 



No cycle; irregular j Less fre- Sometimes tubercle 
or remittent. Sel- q u e n t, bacilli in blood. No 
idom long contin- is m a 1 1 e r; Widal. Leukocyto- 
ued. and if so, long- and usually sis not often, but 
er than in typhoid, ja p p e a r srnore than in ty- 
jE xacerb a t ions later. phoid. 

;with renewed dis- 
semination of tu- 
bercle bacilli. 
Brain involvement 
may lower fever or 
make it variable, 
inversed type. 



Malaria. 



Plasmodium in 
the blood (or 
splenic pulp). 



Pulse moderate in Intermittent, be-Much 
rate; sometimes ginning very often 1 a r g 



Plasmodium, mel- 
anajmia, no leuko- 



iicrotic; very rare- 
ly endocarditis. 



with chills, type more than cytosis save in per- 
Ivaries (quotidian, in typhoid; jnicious forms, 
tertian, etc.); of- and p er-; Great and early 
ten rises high atsists f re- j anaemia. No Widal. 
once; if continuous quently as 
(subcontinuous) at ague-cake, 
least made irregu-i 
lar by quinine or 
usually wholly 
abolished (for 
time at least). 



Sepsis (in- Cultivation of 

eluding En- pyogenic organ- 

docarditis). isms, pneumo- 

coccus, from 

the blood or 

various foci. 



Usually fast and ir- 
regular; cardiac 
localizati ons 
very frequent in 
epsis, puerperal 



Chills, sweats, Especially 
steep elevations, lenlarged 
and sudden depres-lfrom sepsis 
sions almost al-|and in- 
ways at some timejfarcts. Also 
often the 



especially, and in i and usually repeat 
endocarditis (a car- ed with each dis 
diac form of sepsis). I charge into the 
Cardiac enlarge- blood of infective 



ment, thrill, bruit 
accentuated p u 1 
monic tone, etc. 



material. 



lymph- 

nodes. 



Various organisms. 
Marked polymor- 
phonuclear leuko- 
cyotsis very fre- 
quent; sometimes 
absent in endocar- 
ditis. No Widal. 



Meningitis. Lumbar punc- 
ture (a) menin- 
gococci, tuber- 
cle bacilli, py- 
ogenic organ- 
isms, etc.; (&) 
increased, tur- 
bid fluid, etc. 



Rate differs with 
type; variable. 



Differs with vari- 
ety, but seldom as 
high as typhoid; no 
cycle. 



Rare. 



Leukocytosis in ep- 
idemic and puru- 
lent types; rarer in 
tuberculous. No 
Widal. 



TYPHOID FEVER 



45 



Skin 



Roseolse, typical in 
location, crops, ap 
pearance, contain 
ing typhoid bacilli. 
Sweating and mili- 
aria less often and 
later. Icterus rare 
Herpes rare. 



Lungs 



Breathing somewhat 
increased from tox- 
aemia (cerebral 
breathing) hyposta- 
sis, or other compli- 
cations. Rales be- 
low and behind. 
Tympanitic note 
never heard in mili- 
ary tuberculosis. 



Nervous System 



Early headache, re- 
placed later by de- 
lirium, ty p h o i d 
state, actual men- 
ingitis very rare; 
intoxication may 
closely simulate 
meningitis. Very 
rarely disk changes. 



Sputum, Urine 



Alimentary 
Tract 



Typhoid bacilli in 
urine. Diazotestin 
nearly all cases 



Mouse-like breath, 
semi-characteristic 
tongue, ochre-yel- 
low stools, tym- 
pany, diarrhoea, 
bowel hemorrhage, 
perforation, bacilli 
in stools. Retracted 
abdomen or early 
vomiting rare. 



Roseolse absent; 
extremely rare 
and not then in 
crops. Drenching 
sweats common 
Herpes more than 
in typhoid. Skin 
anaemic and very 
often cyanotic. 



Breathing increased 
even 40 to 60; cyano- 
sis and dyspnoea 
without adequate 
physical findings. 
Fine and localized 
rales heard above and 
in front. Tympanitic 
percussion note from 
lung relaxation. Ev- 
idences of pleural ad- 
hesions, apical 
changes, fresh pleu- 
ral rub. 



Meningitis tubercu- 
losa very frequent; 
optic neuritis; cho- 
roidal tubercles. 



In severe, eyes sub- 
icteric or marked- 
ly icteric. Herpes 
very frequent 
and urticaria the 
next most frequent 
exanthem. 



If lung congestion 
(severe forms), it is 
variable, recurrent, 
shifts from lobe to 
lobe. 



Headache at onset 
is rare; later is of 
ten pulsating or 
neuralgic. Delir- 
ium from begin- 
ning in aestivo- 
autumnal forms is 
frequent. Restless- 
ness, anxiousness, 
In pernicious forms 
may have convul 
sions, coma, etc. 



Tubercle bacilli 
sometimes found in 
sputum, urine and 
faeces, but are indi 
cative of old tuber 
culous lesions, not 
of miliary tubercu- 
losis. Diazo test 
frequent. 



Diarrhoea not com- 
mon, but may rare- 
ly occur, as indeed 
may hemorrhages; 
both may come 
from tuberculous 
ulceration of 
bowels. 



Hemoglobinuria in 
pernicious malaria 
Diazo test fairly 
frequent, though 
much less than in 
typhoid. 



Nauseating breath. 
Sometimes abdo- 
minal pain even in 
mild types; may 
rarely have diar- 
rhoea, even hemor- 
rhage in alimentary 
pernicious types. 
Liver congestion 
frequent, also 
icterus. 



Frequent sweating, 
miliaria. Septic 
(polymorphous) 
rashes Subicterus, 
frequently pur- 
puric skin erup- 
tions, herpes not 
uncommon. 



Bronchitis frequent 
Pulmonary infarcts 
and pleurisy. 



Dependent on 
cause. Septic men- 
ingitis (with arth- 
ritis, pleurisy, etc.) 
cerebral embolism; 
retinal hemor- 
rhages or embol- 



Acute embolic 
nephritis. Pepton- 



Septic diarrhoea. 



Herpes in epidemic 
cerebrospinal form. 
Tache cer^brale. 



Variable breathing 
Biot's breathing. 



Early triad, head- 
ache, retracted 
neck and hyper- 
esthesia. H e a d- 
che violent 
throughout the dis- 
ease, convulsions, 
paralysis, Kernig's 
sign, etc. Optic 
neuritis retinal 
hemorrhage, tu- 
bercles in choroid. 



Early cerebral 
vomiting. Re- 
tracted scaphoid 
abdomen. 



46 THE SPECIFIC INFECTIONS 

Trichinosis is differentiated from typhoid by the history, by muscu- 
lar pain and cedema in the striped muscles, by trichinae in the stools 
and muscles, and by eosinophilia. In typhoid these symptoms are 
absent, while the cardinal findings, such as the Widal reaction, rose 
spots, and enlargement of spleen, are present. Two or three cases of 
double infections have been reported (McCrae). 

Prognosis of Typhoid Fever. — The death-rate was formerly 20 
per cent., based on 50,000 cases collected by Jaccoud. At present it is 
lower (5 to 12 per cent.) because of: (a) more accurate diagnosis, 
thus including lighter cases in our figures; (6) the virulence of typhoid 
becoming less; (c) better hygiene; and (d) better treatment, the 
Brand method, etc. 

The prognostic factors are: 

1. Age: The least mortality is between the second and the tenth 
years; the highest after the twenty-fifth. 

2. Constitution: Meagre and muscular patients are more likely to 
recover than the plethoric, adipose, or robust. 

3. Sex is immaterial, aside from pregnancy. 

4. Acute diseases modify the prognosis. These are scarlatina, 
measles, variola, diphtheria (rare), malaria, erysipelas (from 0.7 to 2 
per cent.), varicella, etc. 

5. Chronic diseases, such as gout, diabetes (low temperature, the 
sugar often disappearing), cardiac, pulmonary, and renal disease; 
alcoholism (34 per cent, mortality from weak heart or hemorrhagic 
diathesis) ; convulsive affections, such as epilepsy or chorea, may cease. 

The prognosis is better in relapses than in the original case. 
Recrudescences are dangerous. In war times, the prognosis is usually 
less favorable; the Spanish-American war was an exception, the 
death-rate being but 7 per cent., while in the Boer war the mortality 
was 21 per cent. 

Death usually occurs between the eighteenth and twenty-eighth 
days, and is caused by — 

1. Toxcemia, the most frequent cause of death (30 to 50 percent.), 
including: (a) hyperpyrexia; (b) hemorrhagic types; (c) heart weak- 
ness, vasomotor paralysis; and (d) brain paralysis. 

2. Local typhoid lesions, as meteorism, diarrhoea, peritonitis (in 16 
per cent, of fatal cases), or hemorrhage (in 20 per cent.). 

3. Complications, as lung inflammations (in 10 per cent, to 15 per 
cent.), nephritis (4.5 percent.). Septicaemia (secondary streptococcus 
invasion) has been little studied except by French writers ("forme 
septicemique generalisee ,> ), the symptoms of which are high fever, with 
chills and sweats, abscesses, enlarged glands and spleen. Pyaemia may 
result from acute osteomyelitis, suppurative parotitis, adenitis, phle- 
bitis, or splenic infarction. 

4. Collapse. Sudden death has been discussed under changes in 
the heart muscle. Dieulafoy estimates that sudden death occurs in 2 
per cent, of typhoid cases. The pulse is always more important than 
the fever, and early rapidity is unfavorable. 



TYPHOID FEVER 47 

5. We have already considered the ominous significance of pseudo- 
collapse, the typhoid state, early delirium, diarrhoea, and meteorism ; 
of the various severe complications, such as noma, gangrene, laryngeal 
perichondritis, and pneumonia; and of the more severe types, such as 
the hyperpyretic and hemorrhagic; and of the ambulatory varieties. 
Typhoid beginning suddenly entails a high mortality. 

Treatment. — Duj ardin-Beaumetz said "The best treatment for typhoid 
is a good physician." The treatment concerns (A) prophylaxis; (B) 
specific treatment; (C) hygiene and rest; (D) the question of intestinal 
antisepsis; (E) antipyretic measures (hydrotherapy); (F) diet; (G) 
symptomatic or expectant treatment; (H) treatment during conva- 
lescence. 

(A). Prophylaxis. — Prophylaxis has as wide a scope in medicine as 
asepsis and antisepsis in surgery. In Chicago, during the years 1889 
to 1892, inclusive, there were 4,747 deaths from typhoid. In the four 
years after the drainage-canal was opened there were 2,235 cases; that 
is, per population, the mortality was reduced 75 per cent. In 1905, 
typhoid cases were rare. General prevention is difficult, because of the 
ubiquity of the germ and the carelessness of individuals. Systematic 
cooperation regarding sewage regulation and water supply could 
efface typhoid. Koch has particularly emphasized this point lately 
and succeeded in wiping out certain typhoid foci. One difficulty lies 
in the infrequent recognition of light cases, and another in the selfish 
carelessness of many persons, and a third in the fact that some individ- 
uals "carry bacilli" for years. It is easy to boil water for home use, and 
yet it is done in but few families, even in those of physicians. The 
traveler should avoid unboiled water and milk. In the treatment of a 
case, everything with which the germ may come in contact must be 
sterilized. Next to the faeces, the urine is the most important conveyer 
of the bacillus. They are the usual means of dissemination, and their 
proper disinfection in every case would surely obliterate typhoid. The 
bacilli may persist for years in the urine. Chloride of lime should be 
placed in the bottom of the urinal, or bed-pan, before and after use. 
Acidulated sublimate (1 to 500) or 10-per-cent. crude carbolic solu- 
tion may also be used; but neither at once disinfects, for which reason 
each one of the dejections should be disposed of only after an hour or two. 
Both the pans and urinals must then be sterilized. The same urgent 
disinfection is indicated in the case of thermometers used in the rectum, 
and rectal syringes or tubes. The perineum, after each movement, 
should be sponged with a l-to-2,000 bichloride solution, and also the 
back and thighs, when there are involuntary evacuations. The rubber 
draw-sheets and linen should be sterilized regularly with carbolic acid 
or bichloride of mercury, and the sheets, blankets, pillows, and mattresses, 
steamed when taken off the bed. The bath-tub should be carefully 
cleaned with carbolic solution, as the patient's soiled skin and the 
urine often voided during the bath are obvious sources of danger. It 
seems superfluous to urge cleaning the hands of the nurse or physician 
after examination or tubbing, but the not infrequent direct transmission 



48 THE SPECIFIC INFECTIONS 

of the disease to nurses, orderlies, and doctors, is often forgotten. 
Direct infection is growing in clinical importance. In the Spanish- 
American war 20 per cent, of our soldiers were directly infected 
by flies, and in the Boer war more died of typhoid than were killed by 
bullets, infection being carried by flies and sand. The few cases 
among the Japanese is one of the many lessons they taught us. 

In convalescence the room should be fumigated with formaldehyde, 
not with the useless sulphur method (see Smallpox). 

(B). Specific Treatment. — Specific treatment awaits the further devel- 
opment of serotherapy. Chantemesse, Widal, Brieger, Wassermann, 
Wright, and others, have obtained some results. The injection 
of a sterilized culture sufficiently strong to kill a guinea-pig pro- 
duces local reaction, sometimes nausea, restlessness, fever, increased 
bactericidal power of the blood, and an increase in its agglutination 
properties. Preventive inoculation in India and South Africa reduced 
the percentages of typhoid morbidity from 14 to 2 per cent., and the 
mortality from 3 to \ per cent. The injections used by Chantemesse 
gave him a mortality of but 4 per cent., while the death-rate at that 
time was 12 to 18 per cent, in the other Paris hospitals. 

(C). Hygienic Treatment. — Absolute physical and psychical rest 
is imperative, and the best results occur in cases which have been put 
to bed early. Cases of the ambulatory type, and the ones which for 
any reason are not put to bed at the onset of the typhoid, never fare 
as well. Typhoid patients should not be entertained. The invariable 
use of the bed-pan and urinal should be insisted upon, as every pa- 
tient can learn to use them. In all infections, the furniture, carpets, 
and hangings, should be removed from the room, and it should have 
free ventilation, — fever patients do not catch cold. The sunlight should 
fall across the bed in order to avoid confusing shadows. The nurse 
should have written instructions. The stools, baths, etc., should be 
watched or directed by the physician, especially at the onset. The 
single bed should be low, should have a firm mattress, rubber draw- 
sheet, and perfectly smooth cotton or linen sheets. A second bed 
is desirable for change and convenience. 

(D). Antiseptic Therapy.— Antiseptic therapy is now largely of his- 
torical interest, as typhoid is not a local enteric disease but a septi- 
caemia or bacillsemia. Calomel was given early in typhoid by von 
Ziemssen and Liebermeister, who thought that it reduced the viru- 
lence of the attack and lessened bowel symptoms and complications; 
it is unnecessary, and at the acme is actually harmful. Beta-naphthol, 
grs. v. to x. every four hours, is given by Bouchard and Rossbach. 
Salol (phenylis salicylas) is the least objectionable, since it is mild; 
it is given in doses of grs. x., t. i. d., and has some value as an intes- 
tinal antiseptic. The urine should be closely watched for signs of 
renal irritation. A few drops of hydrochloric acid (the Swedish fever- 
cure), bichloride of mercury, one-thirtieth grain every eight hours 
(Broadbent), or thymol, two grains every three hours in a soap pill, 
are also advised. No one of this group of agents essentially in- 



TYPHOID FEVER 



49 



fluences the clinical course. They are used not against the Bacillus 
typhosus but solely against the common organisms of fermentation. 

(E). Antipyresis. — (1). Drug Antipyretics. — Drug antipyretics in 
typhoid are not often indicated, for they merely reduce fever and do 
not eliminate its cause, the toxins. Quinine is recommended by Lie- 
bermeister and Curschmann, in one or two doses of fifteen to twenty 
grains, given before the fever reaches its highest point. No cardiac 
depression results, and its effects last from eight to twelve hours; 
the fever, however, is but moderately influenced by quinine. Anti- 
pyrin and allied products, in full repeated doses, depress the brain, 
circulation, respiration, and metabolism; cause vomiting and erup- 
tions; and increase the danger of collapse. They are not indicated 
in typhoid as they are in the fugitive fevers. Kryofme, seven to fifteen 
grains, is a good febrifuge, and in the author's experience has never 
caused depression. In practically all cases, drug antipyresis is far 
inferior to — 

(2). Hydrotherapy, which is the only logical method of reducy 
ing temperature, since it alone eliminates the fever-exciting toxins. 
Nature's method of reducing temperature by sweating should not be 
ignored. Evaporation from the moist skin should be helped by re- 
moval of the bed-clothing, (a) The full cold bath of Currie (1787) 
and Brand is given with water at 64° to 68°; it lasts fifteen to twenty 

Fig. 6. 




Burr's bed. 



minutes and is repeated every three hours for temperature of 102° 
or over. Chilling is averted by vigorous friction, which must not 
abrade the skin; by cold affusions to the head; or by administration 
of alcoholic stimulants. The apparent brutality of the Brand 
method has excited considerable popular and professional prejudice, 
but it is more valuable than any other measure in typhoid. As Jur- 

4 



5C THE SPECIFIC INFECTIONS 

gensen remarks, every deviation from the simple principles above out- 
lined gives less satisfactory results. Early resort to hydrotherapy 
gives the best results. When the portable bath-tub is not available, 
the method of A. H. Burr is equally good. He uses a wooden frame, 
shaped like a large : :::: the base fits over any bed: its upper part 
sustains a heavy rubber sheet, which passes under the patient and con- 
stitutes the sides and bottom of the tub Fi^r. 6 . Its use obviates the 

- 
necessity of lifting the patient, and saves excitement. Water is poured 

over the patient from pails and is removed with a siphon. The ad- 
ss of Brand's method are: (i) The mortality is lowered 6 to 
8 per cent. : ii toxtemia is Lessene ::. and therefore nervous and diges- 
tive symptoms, heart weakness, and pulmonary complications, are 
relieved: fever is successfully reduced, and there is less visceral degen- 
eration; 'hi the renal secretion is stimulated, therebv washing the 

■ 

toxins out of the blood, as is shown by a five- or sixfold increase in the 
urotoxic coefficient; iv) the skin becomes more active and bed-sores 
less frequent, although furunculosis is seemingly increased; v the 

clinical course is shorter, and. on the whole, fewer complications occur, 
although the percentage of hemorrhage and perforation is not low- 
ered, and relapses seem slightly more frequent. Conira-indications to 
the use of Brand's method are hemorrhage, perforation, great pros- 
tration, alcoholism, advanced arteriosclerosis or cardiac disease, and 
marked phlebitis. Pregnancy, nephritis, and pneumonia, are not con- 
tra-indications. Various substitutes, for Brand's method, though less 
effectual, may be indicated for special reasons. (6) The gradually 
cooled bath Ziemssen and Immermann? is identical with the Brand 
method, except that the temperature of the water is gradually reduced 
:: u: '. : : : ~'\ : r '/." : . I: is :. ■".:-.:: ~r : ~ ::--- :• :uii:^ ".;:: ::-:- ::e?. :_:-:;: 
late and to those with great dyspncea. or to those tending to collaj 
(c) The protracted tepid bat Riess, Eichhorst. Unverricht). (d) 
Cold sponging, first with warm water to dilate the skin-vessels and 
then with cold water to abstract heat. Equal parts of alcohol and 
water should be mixed, to aid evaporation. One part after another of 
the body is exj >sed and sponged. It is a refreshing and quieting 
placebo, but enormously inferior as an antipyretic. e The cold pack 
is also much less successful. In sthenic cases, ice applications to the 
head, axilla, spine, etc.. may be used, or the body may even be ironed 
with ice. Ice-water enemas are never used in typhoid, though some- 
times employed in other fevers. 

F . Diet. — Fifty ounces of water should be given daily at definite 
intervals, without waiting for the stuporous patient to complain of 
thirst. This flushes the kidneys, lowers temperature by increasing the 
sweat production, and lessens parenchymatous degeneration of the 
era. Pure water is superior to barley- or albumin-water, lemonade, 
etc., which dull the appetite and often derange ligestion. Care of 
the mouth may be : rasidered here. The mouth and pharynx should 
be carefully cleansed of sordes and food particles, lest infection travel 
to the ears, salivary and lymphatic glands, or aspiration pneumonia 



TYPHOID FEVER 51 

result. A boric-acid solution, with tincture of myrrh or tincture of 
hydrastis, meets every requirement. The cleansing must be gentle, in 
order that no fresh abrasions may be inflicted. The diet must be fluid, 
since there are intestinal lesions. It must also be easily digestible, 
since fever lessens all the digestive juices. In the diet no reference 
is usually made to individual symptoms, as there is no correspond- 
ence between the clinical symptoms and the actual anatomical ulcer- 
ation of the intestines. Graves was the first to feed fever patients, 
who up to that time had been starved, but there is, at the present 
time, almost equal danger of overfeeding. Milk is the standard 
diet. Six to eight ounces should be sipped at intervals of three hours, 
day and night, as the patient, after being wakened, readily falls to 
sleep again. It is best given diluted with half an ounce of lime-water 
or with a little carbonated water, which should not be cold, since the 
gas expands at body heat. Though milk alone is said to contain in- 
sufficient albumin to meet the tissue-waste, there is risk of overfeeding; 
and the physician himself should inspect the stools for curds, for 
milk, curdling in the stomach, practically becomes solid food. One 
pint of milk is equivalent to one pint of oysters or a good chop. Very 
few patients cannot take milk. In other words, it can be forced upon 
unwilling patients. Recalcitrant patients may be given some varia- 
tion, such as koumyss, matzoon, buttermilk, whey, or certain baby- 
foods. If the digestion is peculiar or weak, peptonized milk, given 
with very thin, strained gruels, or egg, may be tolerated. Carbohydrates 
are theoretically indicated to lessen nitrogenous waste, and well-boiled 
cornstarch and tapioca are allowed by some clinicians. They are per- 
missible if no tympany results, and the author agrees with Hare that 
taka-diastase aids their assimilation. Meat-juice is obtained from 
freshly slaughtered beef, by a meat-press. If its taste is disagreeable 
to the patient, a few drops of peppermint oil may be given first. It 
may also be given frozen (meat-juice, 5 iij ; sugar, 3 ij- ; lemon-juice, 5 j- ; 
yolk of one egg; cognac, 3 ]•)• The following articles afford some 
variety: Nutrose, somatose, eukasin, Valentine's meat-juice, Brand's 
essence of beef, Mosquera's predigested beef -jelly (containing pine- 
apple juice and over 50 per cent, soluble albumin); yolk of egg in 
soup or wine, and white of egg with twice its weight of water. Foods 
containing gelatin conserve metabolism (Senator) but may irritate the 
bowels. Beef-tea should be avoided, as it contains only stimulating 
substances, less than 1 per cent, albumin, and no fat or carbohydrates. 
Furthermore, it often irritates the kidneys and intestines. In soporose 
patients with anaesthetic throats, food may enter the larynx and cause 
aspiration pneumonia. The nasal catheter is then indicated. To its 
outer end a funnel is attached, through which food, drink, and medi- 
cines, are given. A safety-pin across its outer end prevents its escape 
downward. The catheter should be long enough to pass into 
the oesophagus beyond the larynx, and care should be exercised 
that it does not enter the latter. Rectal feeding is sometimes 
indicated. 



52 THE SPECIFIC INFECTIONS 

(Gr). Symptomatic or Expectant Treatment. — 1. Digestive System. 

(a) Vomiting. — It must be ascertained that the patient has been given 
no solid food by solicitous friends and that perforation has not taken 
place. Rectal feeding, the use of warm carbonated water, cocaine gr. J, 
or tincture iodine m \, for several doses, sinapisms or an ice-bag to 
be placed on the epigastrium, are indicated. Bartholow's formula is 
very serviceable: 

Acidi carbolici gr. iv. 

Bismuthi subnitratis 5iss. 

Cerii oxalatis 5j. 

Sodii brornidi 3ss. 

Sacchari albi -_ 

Acaciae j aa W 

Aquae menthae piperitae q.s. ad §ij. 

M. et ft. emulsio. 

S. — One teaspoonful, undiluted, every 15 to 30 minutes. 

(b) Constipation should be treated with enemas of water or sweet 
oil every other day. Typhoid cases with constipation do better than 
those with diarrhoea. Cathartics are never used, as they cause mete- 
orism. (c) Diarrhoea is most frequently due to toxaemia and is, there- 
fore, most efficaciously treated with the cold bath; curds (prevented 
by diluting the milk), beef-tea, or solid food, may be its cause. Treat- 
ment is indicated when there are more than four movements daily, 
and when there is colic or tenesmus, unrest or weakness. Cold tea 
with whiskey and pulv. aromaticus gr. v., or paregoric and bismuth 
each 5j-> after each movement, extr. opii. gr. l, or the starch-and-laud- 
anum enema usually give relief at once. Pepper considered silver 
nitrate almost specific (gr. J to h). 

Bismuthi subnitratis 5j. 

Morphinae sulphatis gr. j . 

M. et div. in pulv. xij. 

S. — One to four a day. (Alonzo Clark). 

Acidi tannici gr. x. 

Tincturae opii ff£vj. 

Spiritus terebinthinae ttjjxv. 

Mucilaginis 3ij. 

Tincturae chloroformi compositae ir^xx. 

Aquae menthae piperitae ad Bj- 

M. f. haust. 

S. — To be taken every two hours. (Murchison). 

n 

Plumbi acetatis gr. iss ad iij. 

Opii pulveris gr. i ad ijss. 

Sacchari albi gr. lx. 

M. et divide in pulv. vj. 

S. — A powder every three hours. (Yeo). 

(d) Tympany. — This is sometimes an indication that the patient has 
been given solid food. In severe cases albumin-water must be sub- 
stituted for milk. The cold bath often gives relief, since most cases 



TYPHOID FEVER 53 

of meteorism are due to toxaemia. The turpentine stupe of Jenner 
should be applied to the abdomen, flannel cloths being dipped in 
a mixture of warm water and 3 SS 01 - terebinthinse and pressed hard 
together to spread the oil evenly and thus avoid blistering. The ice- 
coil is also beneficial. The old turpentine emulsion of Wood (ol. 
terebinthinse, it£ iij. to v.) is excellent, though the urine must be watched 
carefully for signs of renal irritation: 

01. terebinthinae oiss. 

01. caryophylli gtt. vj. 

Glycerin! . _ i m §ss> 

Mucilagmis acaciae \ 

Syrupi et aquae aa §iss. 

M. et ft. emulsio. 

S. — A dessert spoonful every 3 or 4 hours. 

Whiskey and spices are effective. Emulsio asafcetidse, Oj; Spr. 
chloroformi, 5j- ; and ol. terebinthinae, 5 SS 5 as a warm enema, often give 
relief, (e) Hemorrhage necessitates absolute quiet, mental, physical, 
and alimentary. The patient should not be moved for any reason 
whatever. In severe cases he should lie in the blood which has been 
passed, with cotton tucked around the hips and between the legs to 
catch the urine and fseces, which should pass into it without his being 
lifted on the bed-pan. No food, no water, no enema, no bath, should 
be given. Morphine is primarily indicated. It quiets the excitement 
attending hemorrhage, lessens peristalsis and enforces bodily quiet. 
It should be given in sufficiently large amounts; gr. \ being injected 
every half-hour for three doses, and then a quantity sufficiently large 
to produce its full physiological effects, for the dose of a drug is not 
measured in grains but in its effect; it should be repeated every two, 
four, or six hours in order to sustain the primary indications above 
named. The author has given even four to six grains in the first day, 
when the greatest danger occurs, but in such cases the patient must 
be very closely watched. The author considers that the sole valid 
objection to morphine is that it may mask coincident perforation, 
which occurs once in every five cases of hemorrhage; he believes, 
however, that close circumspection invalidates this objection. Opium 
or styptics by the mouth are dangerous and uncertain. The lead- or 
iron-salts probably never reach the bowel. The ice-coil placed on 
the abdomen may be beneficial. Gelatin may be injected as in aneu- 
rysm (q. v.). The question of stimulation is a difficult one. On the 
one hand, there is the risk of forcing blood through the leak by stimu- 
lation; on the other hand, the volume of blood must not sink too low; 
but first the heart must be allowed to run down, — nature's own and 
most certain method of hemostasis. At a later time only, should 
strychnine or digitalis be administered hypodermatically, or saline 
transfusions be given; and delay in their use is better than haste. (/) 
Perforation necessitates an early diagnosis, which is often difficult, 
and immediate operation, often without general anaesthesia. Most 
reported recoveries were operated on in the first twenty-four hours. 



54 THE SPECIFIC INFECTIONS 

Haggard, Cazin, and Zezas, collated the operations up to 1904-5. 
Recovery occurred in 30 per cent, of 358 operations (Cazin). In twenty 
cases operated on at Johns Hopkins Hospital, 35 per cent, recovered. 

2. Circulatory System. — Heart weakness is best prevented by abso- 
lute rest, and hydrotherapy. An ice-bag placed over the heart tends 
to regulate and calm its action. Strychnine, gr. 5 l o, is the best 
heart tonic, and may be given two or three times a day as a vaso- 
motor tonic in cases which do not show signs of heart-failure. It is 
best, however, to await definite indications for stimulation. Digitalis 
is rarely beneficial in fever cases, and may produce urgent signs of 
cumulative action if the fever should fall. The author has seen one 
case in which, with rather sudden defervescence, the pulse dropped 
from 140 to 40. Camphor, gr. ij., disagrees when given by the mouth 
and should be given under the skin in 1 to 10 parts of sterilized olive 
oil. Other cardiants are considered under valvular disease and pneu- 
monia. Sudden dilatation should be treated by venesection and stimu- 
lation. Alcohol may be considered under this head. In typhoid it 
may be indicated (a) as a food, with milk and eggs, thus aiding diges- 
tion: 5j- to iv. of whiskey may be given every two to four hours in 
hot milk. Stokes's mixture contained cognac, 5ij-5 Vitelli ovi., one; 
Syr. aurantii, 5 v -j water q. s. ad 5 v. Eggnog is valuable as a food 
which may be readily absorbed, (b) As a cardiant (though phar- 
macologists hold that pure alcohol is not a cardiant), Meltzer states 
that it equalizes the circulation. It is indicated especially in young 
alcoholics, and in most cases over forty years of age. Cognac may be 
given by the mouth, in coffee; or by rectum, in peptonized milk 
with two drachms of tincture of valerian, (c) As a nervine in debility 
or old age, as whiskey, champagne (especially for vomiting), sherry, 
or port, id) To a less degree as an antipyretic, since it increases the 
sweat production. Its use must be suspended when the pulse becomes 
bounding, the respiration hurried, the skin or tongue dry, and when 
there is restlessness, or the odor of alcohol appears on the breath. 
Like other good things, alcohol has been abused, and of late the re- 
action against its use is in part sound and in part excessive. With 
care and discretion alcohol is invaluable in severe cases. 

Thrombophlebitis is treated by quiet, elevation, warmth, and ban- 
daging from the toes upward. 

3. Respiratory System. — Epistaxis usually ceases spontaneously. 
If the blood runs into the throat a tampon should be introduced. 
Laryngeal complications may necessitate early tracheotomy. Only 
2 per cent, of severe laryngeal complications recover without opera- 
tion. Bronchitis is treated most efficaciously by hydrotherapy, or 
sometimes, though rarely, by codeine. Expectorants should always 
be avoided since they are likely to produce gastric disorder. Hypo- 
stasis is best treated by hydrotherapy, cardiants, and change of pos- 
ture every two hours, for which written orders should be given. 

4. Nervous System. — The initial headache may be relieved by hy- 
drotherapy, the ice-cap, ergotin and antipyrin, each gr. v., for several 



TYPHUS FEVE'R 55 

doses. Depression is relieved by valerian and whiskey. For delirium, 
and insomnia, hydrotherapy is the most useful measure; veronal, gr. 
v.-vij. in warm water, produces a very natural sleep; alcohol; morphia, 
gr. \; codeine, gr. J; sodium bromide, 5 ss toj.; and hyoscine hydro- 
bromate, gr. ih to so; may be indicated. 

Morphinae hydrochloridi gr. \. 

Sodii bromidi gr. xxxxv. 

Syrupi aurantii 3 iij • 

Aquae chloroformi ad §ij. 

M. f. mist. 

S. — Half to be taken at bed-time, and the remainder in three hours, if necessary. 
(Whitla). 

Typhoid patients should never be left alone, lest they leave the bed 
or leap from the window. Restlessness may suggest a full bladder. 

5. The Skin. — Massage with alcohol or olive oil is useful. The 
skin functions are helped by the full bath. In the formation of bed- 
sores the following are factors : Local heat, pressure, moisture, mace- 
ration, or filth. All of these can generally be avoided by frequent 
changes of posture, thick pads or rubber rings, and cleanliness. In 
some cases great debility may frustrate prophylaxis. The least ery- 
thema, papule, abrasion, or pustule, on dependent parts is a matter 
of solicitude. If bed-sores have already developed, the simplest treat- 
ment is the best, since antiseptics and powders sometimes only aggra- 
vate. The balsam of Peru is excellent. Collodion and adhesive 
straps are always to be avoided as far as possible. 

6. Bacilltjria. — Bacilluria is met by salol and urotropin, each gr. x., 
t. i. d. Special care is necessary in the use of catheters. 

(H). Treatment in Convalescence. — The convalescence must be ac- 
tual, and the possibility of relapses must be excluded before the patient 
can have substantial diet or be allowed to sit up. It is best to err on 
the safe side, as embolism and collapse are not unknown in conva- 
lescence. Eggs, toast, gruels, rice, etc., may be given after one week 
of normal temperature. The patient should not leave his bed for 
two weeks. Irregular fever lingers in some cases until solid food is 
given. In other cases, nitrogenous food will cause a higher tempera- 
ture (febris carnis). Vegetables and fruits should be postponed for 
a few weeks. An excellent tonic in convalescence is the following: 

Strychninae sulphatis gr. j. 

Acidi nitrohydrochlorici . . oj. 

Tr. gentianae co §v. 

M. et S. — One teaspoonful after meals in half a glass of water. 



TYPHUS FEVER 

Synonyms. — Typhus fever; exanthematous typhus; war, prison, 
ship, or famine fever. 



56 THE SPECIFIC INFECTIONS 

Definition. — An acute, highly contagious, specific infection of un- 
known causation; mostly epidemic, with a sudden onset and a high 
temperature, falling by crisis, and with a cyclic curve, a character- 
istic eruption, and severe nervous symptoms. Typhus, first described 
by Corradi (1083), was first clearly distinguished by Fracostorius, in 
Verona (1505). 

Etiology. — All stages of the disease are highly contagious. The virus, 
which is as yet unknown, exists in the exhalations from the skin and 
lungs (Murchison), and survives for a long time in clothing and fur- 
niture. Infection is usually direct from person to person. The dan- 
ger to attending nurses and physicians is therefore great, especially in 
severe epidemics. The more intimate the contact the greater is the 
danger of direct infection. It is also communicable indirectly by a 
third person, by means of fomites, etc. The point of entrance to the 
system is probably the lungs. Cases appear from time to time, the 
history of which cannot be traced. Immunity is usually conferred by 
one attack, but may be congenital. Susceptibility to the disease is 
general. 

Geography. — Ireland, Russia, Galatia, Hungary, Italy, and Mexico, 
are its most frequent homes, and there are always cases in China, 
Asia Minor, and Hungary. It is endemic in Berlin, occurring among 
the lower classes, among vagabonds, and in the unclean, poorly-fed, 
closely-packed and unhygienic population. Typhus was one of the 
greatest scourges of the middle ages, with its wars and famines, but 
it has decreased in the past century, the epidemics in Ireland (1817 
and 1846) and in the Turko-Russian war (1877-78) being the last 
general outbreaks. Its most recent occurrence in this country was 
in New York (1881-82 and 1893), in Philadelphia (1883), and in 
Baltimore in 1901 (Osier). 

Age. — Most cases occur between the fifteenth and twenty-fifth years. 
It is rare in the young or aged, though it has been observed before the 
first year and after the eightieth. It may occur with other epidemics, 
such as typhoid, recurrent fever, malaria, and smallpox. The bac- 
teriology of typhus is undetermined. A streptococcus was found by 
Hlava (1891) and a diplococcus by Dubieff and Bruhl (1893). 

General Clinical Picture. — 1. incubation. — The incubation lasts 
twelve days (seven to fourteen), or less in children, and is usually 
unaccompanied by symptoms. 

2. The Stage of Invasion. — The stage of invasion is sudden, ex- 
hibiting one or more chills and a high temperature on the first day. 
The patient therefore comes early under treatment. Thirst follows, 
with anorexia, coated tongue, nausea, vomiting, epigastric oppression, 
suffusion of the face, conjunctivae, nose, and pharynx; dysphagia, 
apathy, delirium, epistaxis, backache, severe pains in the extremities, 
rapid pulse, and early splenic intumescence. 

3. The Exanthematous Stage. — The exanthematous stage is indi- 
cated on the third or fifth day by a roseolous eruption, at first pale- 
red and purely hypersemic. It is seen first on the abdomen, and 



TYPHUS FEVER 57 

chest, extending rapidly to the back and extremities. The eruption 
then develops a petechial character, with some serous infiltration in 
the centre or edge of the flecks, which become dirty and copper-col- 
ored. It lasts seven to ten days. In this stage there is no pain, but 
often apathy, prostration, delirium or mania. The tongue and mouth 
are dry and dark. Catarrhal inflammations of the pharynx, larynx and 
bronchi develop, with hoarseness and cough. The fever is continuous. 
Coma-vigil, rapid respiration and pulse, and hypostatic pneumonia 
may end the case. 

- 4. Defervescence. — The crisis usually occurs on the tenth to the 
fourteenth day. The defervescence may occupy two or three days 
(lysis). The pulse becomes slower; the skin often desquamates in 
dusky scales; profuse sweats are common; the tongue clears, and 
convalescence is established in from twelve to seventeen days. Long 
defervescence is suggestive of complications. 

Special Symptomatology. — 1. Fever. — After a rigor, the tempera- 
ture rapidly rises to 103°, 105°, or even 107°, on the first or second day 
(Wunderlich). No other acute exanthematous disease produces an 
equally high early temperature. Remissions are few and slight in 
the first week, and the maximum temperature is observed on the 
fifth day. On the tenth day the temperature often remits, except in 
the most severe cases. The crisis occurs from the tenth to the four- 
teenth day, with sweating, exhaustion, relief of symptoms, and often 
with subnormal temperature. Curschmann considers that lysis is as 
frequent as crisis. Remissions rarely occur in this disease. Afebrile 
typhus is rare. So also are precritical elevations and pseudo-crises. 
Death occurs either with a preagonal rise or with collapse of temperature. 

2. The Skin. — The eruption consists of two elements: Roseolas 
changing to petechia?, and a fine, dusky-red mottling under the skin. 
The roseola are seen on the third or the fifth day; they increase rap- 
idly and abundantly, though never in recurrent crops, and are at their 
height within two days. They are located chiefly on the lower ab- 
domen, chest, back or shoulders, are least abundant on the thighs, 
and do not appear on the face except in women and children whose 
skin is delicate. The palms of the hands and the soles of the feet 
are generally exempt. 

The roseola? are pale-red, washed in outline, round or oval, the size 
of a pin-head or a lentil. They are hypera?mic, and therefore dis- 
appear on pressure and after death. They are easily overlooked at 
night. They last one, two, or at the most three days, later becoming 
dark, livid, or copper-colored petechia persisting on pressure and after 
death, because hemorrhagic. The petechia? occur mostly on the back, 
or in the folds of the groin, and may lie between the roseola?. The 
hemorrhage may extend more widely either into the skin or in the 
subcutaneous tissue. Typhus cases presenting no rash are rare. A 
great multiplicity of petechia? is an ominous feature, especially in 
cachectic and alcoholic subjects. A morbilliform eruption on the 
arms and legs is occasionally observed before the usual typhus rash, 



58 THE SPECIFIC INFECTIONS 

especially in thin-skinned individuals. The skin is usually dry, but 
miliaria may appear (in 6 to 10 per cent, of the cases), notably in the 
young. Icterus without decolorization of the stools is frequent and 
is an unfavorable sign. Desquamation occurs, and is sometimes as 
profuse as in scarlatina; herpes occurs in 5 to 20 per cent., and bed- 
sores in 3 per cent, of the cases. The skin has a peculiarly pungent, 
offensive, or ammoniacal odor. 

3. The Nervous System. — This is markedly involved, toxaemia be- 
ing profound. Headache is constant until the exanthem appears; 
it is frontal and temporal, infrequently occipital, and radiates into 
the neck or shoulders. It is associated with vertigo, backache, and 
hyperesthesia of the fingers and toes. The sensorium first shows de- 
pression, characterized by apathy, insomnia, incoherent speech, or 
disturbing dreams, which increase as the pains disappear. In the second 
week coma-vigil, low delirium, mania and hallucinations often de- 
velop. Suicidal tendencies may be noted, especially in the young and 
robust. Involuntary evacuations and noisy cerebral respiration also 
occur. The earlier the nervous symptoms, the more ominous is their 
significance. Neuralgia is occasional in defervescence. It is transient, 
and exists mostly in the lower extremities. Tremor of the forearms 
and hands is almost constant. Convulsions are rare, but ominous. 
They are observed chiefly at the end of the second week in alcoholic 
or very irritable subjects and in children. They are more often epi- 
leptiform than partial, tetanic, or trismic. Paralysis occurs from brain 
hemorrhage, embolism, etc. Cases of paraplegia and aphasia are 
recorded. Meningitis is most rare. 

Special Senses. — There is conjunctival catarrh and the " pin-head 
pupil" of Graves. The ears are involved in 32 per cent, of the 
cases. 

4. Circulation. — The heart and vasomotor system suffer greatly 
(Stokes). The pulse, which is of greatest prognostic value, is small 
and greatly increased, reaching 100 to 120, and even higher in women 
and children. It is slow only in light cases. Dicrotism is rare. It is 
labile and often slow in convalescence. Acute myocarditis may occur 
with acute dilatation, which is highly dangerous, especially in alco- 
holics. Its symptoms are those described under Typhoid. In fatal 
cases the heart muscle is granular and deep-red. The blood is dark 
and fluid; the red cells and haemoglobin are decreased, and the white 
cells are increased. 

5. Respiration. — Epistaxis is occasional. Laryngeal involvement 
varies with the epidemic. Hoarseness, erosions, fissures, ulcerations, 
oedema, and perichondritis, may develop and may possibly lead to 
secondary abscess of the lung or empyema. Catarrh of the upper 
air-passages, bronchitis, and tracheitis, are part of the disease. They 
are present at the onset, increase with the fever, and are evidenced by 
a cough, with a slight expectoration, which is sometimes streaked 
with blood. Catarrh with weak heart results in atelectasis, hypostasis, 
and lobular pneumonia. 



TYPHUS FEVER 59 

Pneumonia occurs in 15 per cent, of typhus cases, usually in the 
second week, and is frequently atypical. 

6. Gastro-Intestinal Tract. — The tongue, at first moist and white, 
becomes dry and dark — the " parrot tongue." Thirst is common. 
Nausea and vomiting are fairly common, and meteorism is infrequent. 
The epigastrium only is tender. The liver is swollen, soft, and grayish. 
There is usually constipation (90 per cent, of the cases), although diar- 
rhoea may appear at the crisis. Gastro-intestinal hemorrhage, a 
hemorrhagic diathesis, diphtheritic ulcerations, parotitis, ulceration of 
the oesophagus and pharynx, phlegmons, and peritonitis, are infrequent. 

7. Genito-Urinary Tract. — The urine is febrile. The urea is often 
decreased but may be increased after the crisis. The chlorides are de- 
creased or may be absent entirely. Albumin frequently appears in 
the second week. Nephritis (in 6 per cent, of the cases) is dangerous. 
Uraemia and hsematuria are rare. The urine will frequently show the 
diazo reaction. Diacetone, leucin, and tyrosin, may be found. Dys- 
uria, orchitis, and menstrual disturbances, occasionally occur. 

8. Spleen and Glands. — An early splenic tumor is palpable in 33 
to 66 per cent, of the cases. It disappears late in the second week. The 
splenic pulp is fluid and degenerated. Rupture has been described. 
The lymphatic glands are not usually enlarged, though adenitis was 
noted during the Crimean and Turko-Russian epidemics. 

Recurrence. — This is very rare in typhus. It happened only once 
in 5,000 cases (Buchanan). 

Anomalous Courses. — Light forms run a course of six to ten days, 
with less fever, fewer nervous symptoms, and less rapid pulse than in 
the more severe types. They include the abortive type without erup- 
tion, and the ambulatory type. Very severe forms are the hyper- 
pyretic (fatal in two to three days), or the adynamic (in which the 
patient dies with low temperature, hemorrhages, etc.). Complication 
with other diseases, or the patient's advanced age, may intensify the 
symptoms. 

Differentiation. — This is not difficult if the case is seen from begin- 
ning to end, or during an epidemic. There are no absolute pathologi- 
cal or bacteriological criteria. Mistakes in the diagnosis of sporadic 
cases are often inevitable. In the initial stage only a probable diag- 
nosis can be made. 

In smallpox the chills, fever, prostration, severe aches, splenic 
tumor, and backache, are not final, since they are less marked in 
mild forms of the disease. The initial scarlatiniform eruption in the 
angles of the arms and groins is characteristic of smallpox. The mor- 
billiform eruptions occur also in typhus. Smallpox invades the face 
more than does typhus, and the relation of the eruption to the tem- 
perature remission is not observed in typhus. Even at postmortem 
examinations, differentiation between the hemorrhagic form of typhus 
and the purpura variolosa is frequently impossible. 

In recurrent fever, the fever-curve is important, but the diagnosis 
may be difficult during the first attack. The history, the lack of in- 



60 



THE SPECIFIC IXFECTIOXS 



volvement of the sensorium, the generallv favorable condition of the 
patient, the absence of pain, the characteristic anaemic yellow-gray 
skin, the spirilla and successive attacks, indicate recurrent fever. 

In irregular epidemics, meningitis, with chills, fever, nervous symp- 
toms, coma, and headache (without rigid neck and with a roseolous 
eruption), at first presents difficulties, though in the later course, it 
may be distinguished after lumbar puncture and examination of the 
retinae. The eruption is at first roseolous but later is petechial. If the 
petechia? occur first, the disease is not typhus. 



Typhus. 

Invasion: sudden; chill, coryza. 

Roseola: More numerous and earlier, 
second day to fifth day. 

Never in crops. 

Distribution on body and extremities. 

Sparingly on face. 

Flat, pale, washed, hyperaemic, not 

disappearing upon pressure when 

they become petechial. 

Course: more rapid. 

Face and eyes injected. 

Fever: abrupt rise, higher, less remis- 
sion, if any; shorter; crisis or, short 
lysis, on fourteenth day. 

Soon bedridden. 

Earlier and severer nervous symptoms. 

Pulse: rapid and not dicrotic. 

Spleen: early swelling, but less frequent. 

Less meteorism or none. 
Stools: not characteristic. 
Blood: leukocvtosis. 



Typhoid. 

Slower and more gradual; no coryza. 

Usually less points of eruption (are ex- 
ceptions, — e. g. measles-like); in ex- 
tremities, as in Franco-German war. 

In successive crops. 

On body; rarely on extremities. 

Almost never on face. 

Papular, pink, sharply outlined, always 
hyperaemic, disappearing upon pres- 
sure. 

Slower. 

Paler; conjunctivitis rare. 

Slow rise and regular stages. 

Oftener ambulatory. 

Second week or later, and less severe. 

Dicrotism of less importance than slow- 
ness. 

Later, but lasts longer; two or three 
times more frequent. 

Meteorism. 

Ochre-stools. 

Leukopenia, Widal reaction; bacteria 
in blood, urine, roseolae. 



Diazo Reaction in Both. 

In Measles the face is the first seat of eruption; the rash is rarely 
hemorrhagic; catarrhal symptoms precede the eruption, when the 
fever again rises. Typhus is rare under five years of age. 

Prognosis. — The prognosis depends upon the intensity of the tox- 
aemia, the fever, the nervous symptoms, and on the complications — 
especially pneumonia. Death from toxaemia usually occurs in the 



RECURRENT FEVER 61 

second week (twelfth day); from pneumonia in the third week. The 
mortality varies between 6 and 20 percent., but reaches 50 percent, 
in virulent epidemics and in patients over fifty years of age. Children 
rarely die of typhus. 

Treatment. — The treatment is that of typhoid, with the added in- 
dication of strict isolation. Open-air treatment in tents is indicated, 
with thorough disinfection of everything coming in contact with the 
patient. Cardiac stimulants are more often required than in typhoid. 

RECURRENT FEVER. 

Synonyms. — Relapsing fever; febris recurrens; typhus recurrens; 
seven-day fever; famine or prison fever; bilious typhoid. 

Definition. — A specific infectious disease caused by Obermeier's 
spirillum; acquired more often by direct personal contact than by 
indirect infection; endemic in Ireland, Russian Poland, and India, 
though sometimes epidemic ; clinically characterized by a cyclic course 
of febrile attacks lasting six or seven days, followed by an equally 
long apyretic interval, which cycle may be repeated several times. 

Etiology. — Recurrent fever has been known for nearly two cen- 
turies. It was first described by Rutty, of Dublin, in 1739. It ap- 
peared in America in 1844, and was last seen in 1869. Obermeier in 
1873 described a specific spirillum or spirochseta (Spirillum Ober- 
meieri). Recurrent fever is transmitted not by the spirillum itself, 
but by its spores, since the disease may recur after the spirillum has 
been killed by quinine. The spores are possibly the glistening bodies 
sometimes seen in the blood {q. v.). The breath and exhalations 
are infectious, though less so than in typhus. The secretions are ap- 
parently not infectious. The disease has been inoculated in monkeys 
and in man, from postmortem cuts. Bed-bugs may also convey it. 
Infection is carried chiefly by vagabonds and emigrants. Males are 
especially affected (80 to 98 per cent.). Most cases occur between the 
twentieth and the fortieth years. It is rare after forty-five, and has 
been seen in the foetus. Epidemics may occur with typhus, and more 
rarely with typhoid, malaria, or smallpox. 

Symptoms. — Incubation. — After an incubation of from five to seven 
days, the invasion occurs, usually, without prodromes. 

The Invasion. — The invasion begins with a chill, a high tempera- 
ture (reaching possibly 104° on the first day), a throbbing headache, 
and, in the young, convulsions and vomiting. The vertigo and cere- 
bral confusion may resemble acute alcoholism. Because of the severe 
neuralgic pain in the back, legs, and calves, the patient lies motion- 
less. There is great depression, conjunctival suffusion, slightly icteric 
sclera?, a pale (even cachectic) facial color, epigastric oppression with 
or without vomiting, and tenderness over the liver and spleen. 

The Specific Findings are in (1) the blood; (2) the spleen; (3) the 
bone-marrow. 



62 THE SPECIFIC INFECTIONS 

1. The blood is dark and reveals the pathognomonic, motile, cork- 
screw-shaped spirillum, which is found usually with the appearance of 
the fever, though occasionally a few hours before. 

It often disappears and becomes less motile before the fever falls; 
and is, on rare occasions, found from one to three, or even fourteen days 
after the fever. It appears again with the next attack. The spirillum 
is found in the blood only. The number is variable and not propor- 
tionate to the severity of the disease; as, for instance one spirillum in 
ten to seventy fields at first, and twelve to thirty spirilla in a field at the 
acme. Without the immersion-lens, they may be located by the lashing 
about of the red cells. They always lie between and never in them, 
and appear as fine threads, sixteen to forty millimeters in length, 
with five to ten waves in each, and move by undulation along their long 
axes. They stain best with fuchsin, after the extraction of the haemo- 
globin by acetic acid. Their life in the blood is usually thirty -seven 
days. 

The white blood-cells are increased. Large, fatty, granular pioto- 
plasma-cells, probably from the spleen, may sometimes be seen. 

2. The spleen is nearly always enlarged, painful, and palpable, and 
varies in size directly with the temperature. According to Leube, in no 
other infectious disease is the spleen so large, being increased five- to 
sixfold and weighing even twenty pounds. The capsule is tense, 
sometimes with perisplenic adhesions, and the pulp is a fluid-red. The 
Malpighian bodies are increased, and necrotic areas and infarcts are 
common. Suppuration and rupture (6 per cent, of the cases) may occur. 
Microscopically there are hyperemia, hyperplasia, spirilla, large fatty 
cells (in the portal and other vessels), and fatty desquamated 
endothelium from the veins, thus explaining the spindle-cells found in 
the blood-stream. 

3. The bone-marrow resembles the splenic follicles and contains 
many granular cells, and, occasionally, aggregations of white blood-cells. 

Other Symptoms.— 1. Nervous System. — Headache is frequent. 
The sensorium is usually free, delirium and insomnia being rare. 

2. Temperature. — The temperature rises abruptly to 103° or 104,° and 
remains continuously high (105.8° to 107.6°), from five to seven days, 
when the crisis occurs. In no other disease is the defervescence so 
precipitate (Leube). The fever falls 5° to 13° (even 16°). In from five 
to seven days the patient is well, when in 99 per cent of cases the cycle 
is repeated. In the second or following attack there may be no chill. 
There are usually but two or three relapses, though as many as seven 
have been recorded, each successive one being shorter by one to one 
and one-half days. The temperature-curve is diagnostic. Lysis is rare 
(1 to 2 per cent, of the cases). The crisis is followed by rapid convales- 
cence, sweats, shrinkage of the spleen, and disappearance of the spiril- 
lum; sometimes post-critical diarrhoea and collapse develop. 

3. Circulatory System. — The pulse is rapid (120 to 140). Compared 
with the temperature, it is full and hard, seldom dicrotic, sometimes 
irregular, and often slow after the crisis. 



RECURRENT FEVER 



63 



4. Respiratory Tract. — Bronchitis (20 to 47 per cent, of the cases) and 
increased respirations (thirty or more) have been observed. In fatal 
cases atelectasis, hypostasis, pneumonia (40 per cent.), glottis oedema 
(31 per cent.), and pleurisy (2 to 3 per cent.), have been found. 

























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Fever chart in recurrent fever. 

5. Gastro-Intestinal Tract. — The tongue is, at first, white and later 
becomes yellow-brown. The appetite may be unimpaired. Heemate- 
mesis, a tender and swollen liver, icterus (8 to 25 per cent, of the cases), 
gall-bladder distention, bloody effusions in the alimentary mucosa, and 
hyperplasia of the lymphatics, may be observed. 

6. Genito-Urinary Tract. — The urinary findings resemble those of 
typhoid. Nephritis is infrequent (2 to 4 per cent, of the cases), and 
abortion occurs in 66 to 100 per cent. 

7. Skin. — The skin is usually subicteric, yet the stools remain 
colored. Herpes (2 to 32 per cent, of the cases), oedema, erythema, 
petechia?, urticaria, desquamation, and even roseolse, have been noted. 
The hot and dry skin becomes drenched at the crisis. 

Diagnosis. — The specific points are: A prevailing epidemic ; onset 
with chill and fever; swelling and tenderness of the liver and spleen; 
muscular pains; an abrupt crisis; an apyretic interval with recurrence 
of the cycle, and the spirilla found by blood examination. 

Loeventhal has found that the serum acts as a bactericide on the 
spirochaetse. In the bilious type (bilious typhoid or septic recurrent 
fever), there is severe icterus, destruction of the red corpuscles, and 



64 THE SPECIFIC INFECTIONS 

pathological liver-findings which are suggestive of acute yellow atrophy. 
Hemorrhages,, involvement of the sensoriuru, and death from collapse 
in the first attack [60 per cent, of the cases , are common. The colored 
stools, rapid pulse, severe bronchitis, and enlarged spleen, are significant. 
Malaria, typhoid, typhus, yellow fever, acute yellow atrophy of the 
liver, and Weil's disease, are excluded by one examination of the blood. 

Complications of recurrent fever include pneumonia and other 
lesions already mentioned. Meningeal hemorrhages, psychopathies, 
paralysis, neuritis, and eye complications, are very infrequent. 

Convalescence. — Convalescence is rapid, after four or five weeks. 
Death may occur from toxaemia, heart collapse, or from complications. 
The prognosis is good, the mortality averaging 2 to 10 per cent., although 
reaching 60 per cent, in the bilious type. One attack is not certain to 
confer immunity. 

Treatment. — The treatment is that of typhoid, as no drug has any 
effect on the parasites. Pain often necessitates the use of opiates. The 
heart weakness is treated as it is in typhoid. 



SMALLPOX AND VARIOLA. VACCINATION. 

Definition. — Smallpox is an acute, highly infectious, specific disease. 
It begins suddenly with a chill, headache, vomiting, and intense 
epigastric and lumbar pain, and is characterized by a typical fever- 
curve and by an eruption on the skin and contiguous mucous sur- 
faces consisting of papules, vesicles, pustules, and crusts in successive 
stages. 

History. — Smallpox is said to have prevailed in China many cen- 
turies before the Christian era. Galen's pesta magna of the second 
century is thought to have been variola. Epidemics occurred in the 
sixth century, and during the crusades. Rhazes (Arabia, ninth cen- 
tury' gave us the first accurate clinical description of the disease. 
Smallpox was introduced into Mexico in 1520, by the Spaniards, and 
three and a half million persons contracted the disease. Sydenham's 
classic of the seventeenth century is most accurate and reliable. In 1718, 
Lady Montague introduced into England preventive inoculation, 
which had been practiced for centuries in Asia, and, though she reduced 
the mortality by this means to 1 per cent, or less, she only disseminated 
the disease in a mitigated form. Jenner's discovery of vaccination, in 
1796, has greatly lessened the terrors of variola, which in Europe 
alone carried off nearly half a ruillion persons yearly, and in Iceland 
cost the lives of 36 per cent, of the population. 

Etiology. — The virus is still imperfectly known. Weigert and others 
have found pyogenic organisms, although suppuration is due to a later 
mixed infection. Protozoa were first mentioned by Van der Loeff, in 
1886. The ciftorytes variolas of Guarnieri 1892 is an amoeba found in 
the blood in the incipient stage, in that of vaccinated children and of 



SMALLPOX AND VARIOLA. VACCINATION 65 

calves, and in the exanthem. Pfeiffer, Roger, Weil, Funck, Copeman, 
Councilman, Mallory, Calkins, Howard, and Perkins, have found 
similar structures. Small bodies are found in the lower epithelial lay- 
ers. These bodies are structureless, measure one to four microns, and lie 
in vacuoles in the cells. They enlarge and become granular and seg- 
mented. 

The virus causes constitutional infection before the eruption appears. 
The greatest infectiousness is noted during the eruption. Its chief 
sources are the dried pustules in which the virus localizes. That the 
blood is infectious at an early stage was demonstrated by the devel- 
opment of the disease in an individual on whom skin had been 
transplanted .from a person in the early stages of smallpox. Variola 
without eruption is contagious, and it therefore seems that the secre- 
tions, excretions, and exhalations, convey the virus. The virus adheres 
to objects having rough surfaces, such as bedding, clothing, public con- 
veyances, and money. The disease persists in infected communities 
for years, becoming quiescent, and afterwards breaking out anew. 
Infection may be direct from person to person, or indirect by a third 
party or by fomites. Cadavers of variola victims are dangerous. In 
short, every new case comes directly or indirectly from a patient with 
variola. The virus is very penetrative, and infection may exist beyond 
the room, the building, or the area of the isolated case. 

The chief factor in dissemination is human intercourse, and not 
telluric, atmospheric, or clinical conditions. Susceptibility to smallpox 
is almost universal, although individual disposition plays a great role. 
Only 1 per cent, of people are immune. Some can never be successfully 
vaccinated. Individual immunity was noted by Morgagni, Boerhave, 
and Diemerbroeck. The author knows two persons in whom vaccination 
has never been successful. Temporary immunity is more frequent 
than congenital, which, however, has been observed. Ordinarily and 
practically, immunity is only acquired by vaccination or a previous 
attack. In prehistoric times, inoculation was practiced to afford immu- 
nity. Second attacks are infrequent. Either sex and all ages may be 
affected. Mothers with the disease may deliver babes with the florid 
eruption or with scars. Some children born in pest-houses escape if 
vaccinated, but most of them die. The virulence of the virus is great 
in aboriginal and colored races (Indians and Mexicans), and in preg- 
nant or menstruating women. Though it varies in different epidemics, 
vaccination is more important than virulence per se. Severe cases may 
follow mild infection, as shown in Osier's description of the Montreal 
epidemic, in which 3,164 persons, infected by a mild case in a Pullman- 
car conductor, died among the French Canadians, who oppose vaccina- 
tion. It is frequently conveyed by vagrants. 

Point of Entrance. — Smallpox infection unquestionably occurs 
through the respiratory tract, and perhaps also through the digestive 
tract. Variola may coexist with or closely follow measles, scarlatina, 
syphilis, erysipelas, pemphigus, typhoid, malaria, and tuberculosis. 
Variola occurs sporadically, epidemically, or panepidemically. 



66 



THE SPECIFIC INFECTIONS 



Symptoms. — Forms : 

I. Variola Vera 

II. Variola 
Hemorrhagica 

III. Varioloid 



— 1. Discreta, discrete. 

— 2. Confluens, confluent. 

— 3. Purpura variolosa (black smallpox). 

— 4. Variola hemorrhagica pustulosa. 

— 5. Smallpox modified by vaccination. 



1. Variola Vera Discreta. — Pfeiffer's Table, with fever-curve. 



Fig. 8. 




TEMP. 

lOi . 




103 \J\a 


1X\ " 


J 1/ 


d.%r 


/ \ /\- 


L \K~~ 


m / 1 a /_\ A 


M\t ' y\h 


- -J- yy^ 


/TV \r\ 


1 


_L 



INCUBATION PRODROMAL 'STAGE, ERUPTION OF MACULES ERUPTION OF SUPPURATION EXSICCATION & 
12 DAYS ,"3,DAXS AND PAPULES 3 DAYS VESICLES 3 DAYS DECRUSTATION 

2 DAYS 7 DAYS 

Temperature chart and stages of smallpox (Pfeiffer.) 

{A). The Incubation. — The incubation, or period of latency 
ranges from five to twenty days, and averages twelve days. It lasts 
eight days after inoculation, and usually presents no symptoms, though 
sometimes there may be headache, anorexia, and pharyngitis. 

(B). The Prodromal Stage. — The prodromal stage, (initial stage, 
or stage of invasion,) dating from the first symptom to the cutaneous 
eruption, is the same in all types, and its duration averages three 
days (rarely six to fourteen). It is shorter in children (Rilliez and 
Barthet) and in the confluent type of the disease; the longer it is, the 
more severe is the infection (Trousseau). Its intensity bears no in- 
variable relation to prognosis, for varioloid (mild smallpox), may 
present a severe onset; if the onset, however, is mild, the disease will 
not be confluent or hemorrhagic in form. Prodromal symptoms are 
absent in rare instances. 

The invasion begins acutely with chill, fever, rapid pulse and respira- 
tion, nervous toxsemic symptoms, intense headache, and backache, 
vomiting, and other symptoms, all of which will be considered in 
detail: (a) The chill is usually severe, and is frequently repeated. 
It may follow one or two days of fever (Jaccoud). In children it is 
often absent. (6) The initial fever is almost invariably high, rising 
suddenly to 103° or 104°, and reaching its maximum on the second or 
third day. In rare instances there is no fever, (c) The pulse is rapid 
(120), full, and not often dicrotic except in severe cases. The more 
frequent respiration (30 to 36) is somewhat characteristic, constituting 
the so-called toxsemic or "cerebral respiration." (d) The skin is red, 
excessively hot (calor mordax), and usually dry, but there may be 
sweating in the discrete variety (Sydenham) and in favorable cases 
(Trousseau). The face is flushed but the eyes are clear, (e) Nervous 



SMALLPOX AND VARIOLA. VACCINATION 67 

toxaemia is evidenced by the benumbed sensorium, depression, restless- 
ness, insomnia, delirium (especially in alcoholics), or convulsions and 
meningeal symptoms in children. Coma is rare. Headache is almost 
constant, usually appearing with or just before the chill. It is fre- 
quently frontal or temporal, and may be generalized, occipital, or 
neuralgic. When severe or agonizing in character, it may be suggest- 
ive of meningitis, especially when accompanied by delirium, hard 
vomiting, and neckache. (/) Backache appears with the chill, and 
lasts one or two days. It occurs in nearly all cases (certainly in over 
50 per cent.), though it is rather less frequent than headache and 
vomiting. It is severe like lumbago, or actually agonizing. The 
"veritable paraplegia" described by Trousseau is usually only immo- 
bility due to pain caused by toxins or by intense congestion (Jaccoud) 
of the kidneys, spinal muscles, or meninges. It is rare in other fevers 
likely to be confused with variola. Pain is sometimes observed in the 
pharynx, larynx, or heart, and produces a sensation of constriction; 
in the chest it results in oppression or actual dyspnoea; it may occur in 
the intercostal nerves, sciatics, colon, bladder, muscles, and joints. 
(g) Vomiting and early epigastric pain (especially constant in chil- 
dren) occur with other febrile digestive symptoms. The spleen is not 
often enlarged in the initial period. It is often tender, as are the liver 
and epigastrium, (h) The initial or prodromal eruptions, studied 
especially by Sydenham, Simon, Osier, Knecht, and Scheby-Busch, are 
present in 10 to 16 per cent, of the cases. They vary with the epidemic 
and have considerable diagnostic value. They may be general but are 
more commonly limited to the lower abdomen, the inside of the thighs, 
the sides of the thorax, the axillae, and sometimes to the extensor sur- 
faces of the knees and the elbows (Simon). There are two varieties: 

1. The morbilliform variety (measles-like, roseola variolosa), which 
appears during the second day on the face and body as small maculae. 
These are sometimes crescentic, disappear upon pressure, and usually 
have a life of one day with complete involution, although in exceptional 
cases they remain until the smallpox papules appear. They are due 
to hyperaemia but are often purpuric, occurring without the measles 
catarrh. They are seen most often in varioloid, and therefore have a 
favorable prognostic import. 

2. The scarlatinal form (erythema variolosum) is more rare than the 
morbilliform variety and occurs earlier, either on the first day, or 
before any other symptoms. It is less punctate, extensive, and bright, 
than it is in scarlet fever. If it is purple in color and purpuric, it is 
almost always variolous. It occurs on the lower abdomen, and on the 
thighs (forming a triangle with base upwards when the legs are to- 
gether), but may even reach the knees. Sometimes it is found on the 
axilla or over the shoulders, and is seen in women more frequently 
than in men. These areas are rarely invaded by the pustular eruption 
(Trousseau and Hebra; though denied by Eichhorst). Some writers 
(Gigon, Barthelemy) speak of an erysipelas-like prodromal rash, and 
Osier and others have observed prodromal urticaria. 



68 THE SPECIFIC INFECTIONS 

(C). The Eruptive Stage. — The eruptive stage consists of several 
serial sub-stages: 

1. The stage of macules and papules (stadium macidosum et papu- 
losum) occurs on the fourth day, and advances for three days. The 
eruption begins on the forehead near the hair and on the cheek, with 
itching and burning macules, resembling flea-bites, which soon become 
papules (like those of prurigo or lichen, Trousseau). The papules are 
reddish, discrete, circular, elevated, and hard or "shotty." They may 
be observed in photographs taken a number of hours before they can 
be seen by the naked eye. A day after their eruption on the face and 
head, they appear on the body, and on the next succeeding day they 
appear on the extensor aspects of the extremities; i. e., the papular 
eruption advances for three days, and is descending. In children the 
papules may develop first near the groin. The papules are thickest on 
the face and trunk. Sometimes they are very thick on the neck. The 
eye-lids are cedematous. According to Stokes, the amount of the 
eruption depends on the vascularity of the part. Trousseau and 
Sydenham maintained that if the eruption appeared on the second day 
of the disease, the confluent type might be expected; if on the third or 
fourth (or even the fifth) day, the discrete type might be anticipated. 
If the eruption ceases at this point, the disease is called variola cornea, 
or verrucosa. 

Weigert holds that the first skin changes are not inflammatory but 
necrobiotic or diphtheroid, and that inflammation begins later with 
exudation into and about the necrotic areas in the rete Malphigii. 
Other authorities consider inflammation the primary, and necrosis the 
secondary process. 

Unlike measles and scarlatina, the fever remits when the eruption 
appears, and the backache, and headache improve. In two or three 
days the fever reaches normal by irregular steps. The lower the fever 
falls in this remission, the lighter is the type of smallpox. 

2. In the stage of vesiculation (stadium vesiculosum), lymph gathers 
in many but not in all of the papules. This occurs on the seventh day 
of the disease and lasts about two days. The vesicles are multilocular, 
since they occur in the cells of the rete Malpighii (Weigert). Umbilica- 
tion occurs in the centres of many vesicles, caused by elevation of their 
edges by infiltration and by the follicles in their centers. It corresponds 
to the area of primary necrosis and is suggestive but not pathognomonic 
of smallpox (Jaccoud, Eichhorst). On the soles of the feet and the 
palms of the hands the fluid is situated deep in the resistant tissues. 
(If the changes stop short of pustulation, the disease is called variola 
crystallina.) The mucous membranes may be the seat of simple 
inflammation, specific eruption, or pseudomernbrane. 

3. The stage of suppuration (stadium pustulosum) or maturation 
begins on the ninth day with clouding of the vesicles and with inflam- 
matory congestion (areola) about them. It advances for usually three 
and rarely more than five days. Increased mucous membrane catarrh 
develops simultaneously with the cutaneous eruption. The pustules 



SMALLPOX AND VARIOLA. VACCINATION 69 

become opaque, then yellow, and the thick pus obliterates the umbilica- 
tion and renders the eruption globular. The areola, or halo, becomes 
more vivid and inflammatory oedema may result from fusion of 
the areolae. This causes increased tension, deformity (especially in the 
face and parts where the skin is most loose), closure of the eyes, occlu- 
sion of the nose (of particular moment in children), and great tender- 
ness and pain. Pustulation follows the descending order of the initial 
eruption and the pustules are less thick on the trunk than on the 
extremities and head. On the volar and plantar surfaces they are less 
prominent and there is less oedema. The pustules evacuate spontane- 
ously, especially on the face, but may dry without rupture. Various 
stages of the eruption may be observed in different parts of the 
body at the same time; not all vesicles become pustules. The skin 
.exhales a peculiar, penetrating, offensive odor, and bed-sores may 
develop. 

(Anomalies are variola abortiva, in which the pustular stage is not 
reached; variola siliqiiosa, — air in the vesicles or pustules; and very 
large eruptions three quarters of an inch in diameter.) 

Pathologically, the pus originates from the vessels of the papilla?, 
which may undergo much pressure, atrophy, or even necrosis. 

The mucous membranes are involved in various ways, but the pock 
eruption occurs mostly in the upper mucosae (mouth and nasopharynx), 
and therein resembles its cutaneous distribution; the successive 
stages of papulation, vesiculation, pustulation, and crustation, may 
develop, but they are less typical than in the cutaneous eruption; 
erosions often result with diffuse catarrhal stomatitis, and sometimes 
with glossitis, phlegmonous angina, etc. The eruption has been found 
in very rare instances in the external ear, Eustachian tube, eye, oesopha- 
gus, larnyx (with oedema or perichondritis), trachea and bronchi 
(mostly erosions), stomach and intestines with swelling of Peyer's 
patches, rectum, bladder, cervix, prepuce, distal end of the urethra, 
vulva, and vagina, with appropriate symptoms of local irritation. 
Pathologically, the changes resemble those in the skin, but they have 
been less thoroughly studied. 

With pustulation there is in most cases a gradual rise in temperature, 
secondary jever, the fever of suppuration. It is never sudden, is some- 
times associated with chills, especially in women and children and in 
nervous patients, and is due to the smallpox virus and mixed pyogenic 
infection. The duration of the rise is proportionate to the degree of 
pustulation and of dermatitis. In variola discreta the temperature 
does not remain high more than twenty-four to thirty-six hours, with 
morning remissions. A marked leukocytosis attends the fever, or it may 
even precede suppuration by one, two, or three days. It parallels the 
degree of infection and may even attain 30,000 to 34,000 cells per 
cubic millimeter. It ceases with involution unless complications inter- 
vene. The lymphocytes are increased (to 50 or 66 percent.), the eosin- 
philes are decreased (to 50 or 33 per cent.), and the myelocytes may 
reach 10 to 12 per cent. 



70 THE SPECIFIC INFECTIONS 

The red cells occur in clumps rather than in rouleaux, and some 
deglobulization, even as low as 2,000,000, is observed. The fever may 
show a preagonal increase or collapse. Hyperpyrexia may occur. 
Repeated rises in temperature are very dangerous. Cerebral symptoms 
occur, such as great excitement, or delirium with suicidal tendencies, 
as happened in the case of one of the author's classmates. Albuminuria 
(33 per cent, of the cases), acute exhaustion, and heart paralysis, 
especially in the aged, may develop. 

(D). The Stage of Involution. — The stage of involution (exsicca- 
tion, decrustation), begins on the twelfth day. It occurs in the same 
descending order as the norition and suppuration, first on the head, 
then on the body, etc., with decrease in the oedema, in the redness, and 
in the pain. As the pain decreases, there is an intolerable itching and 
some pigmentation. Crusts form, and remain longest on the soles of 
the feet and palms of the hands where they may form complete casts 
of the part. Mucous erosions heal more readily than crusts. The 
hair falls out, and by the end of the second week the fever reaches 
normal. There is no desiccation fever, as claimed by some writers, 
and fever at this stage indicates some complication. Scars result from 
the granulations, and the higher the granulating surface, the deeper is 
the cicatrix. Scars occur when the true skin has been involved, and 
are seen chiefly on the face, scalp, palms of the hands, and soles of the 
feet. Sydenham's statement, that discrete smallpox rarely leaves its 
mark, holds good in most cases, according to Osier. Others hold that 
variola vera implies suppuration with fever and cicatrices as necessary 
stigmata. Complete convalescence, according to Jaeeoud, follows the 
disappearance of the last crust. Scar formation lasts three or four 
weeks. 

2. Variola Vera Confluens. — This is a malignant type, which was 
more frequently observed in prevaccination days, and is now seen 
largely in unvaccinated persons or in those vaccinated but once. 
Personal tendency, the genius epidemic us, and propagation per con- 
tinuum, further the development of this type. The initial stage is 
violent. The headache and backache are agonizing. The status 
typhosus and gastric symptoms are marked, the fever remission is slight 
or absent, and there is little or no improvement in the symptoms when 
the fall in temperature occurs. The exanthem is precipitate both in 
its development (on the second or third day), and in its extension. The 
earlier the exanthem in variola (e. g., on third day), the greater is the 
probability of confluent smallpox. The patient usually dies if the 
eruption does not appear. The eruption becomes confluent especially 
on the face and head, and sometimes also upon the hands and feet; 
whereas on the body and limbs it is largely discrete. TVith fusion of the 
eruption, great inflammatory oedema appears, the symptoms increase, 
swelling and erosion of the mucous membranes, closure of the eyes, 
keratitis, and obstruction of the nose, develop. 

The general aspect is desperate. High fever, high pulse, rapid, 
noisv, even irregular or stertorous breathing, delirium, albuminuria, 



SMALLPOX AND VARIOLA. VACCINATION 71 

persistent nausea and vomiting, great thirst, salivation in adults and 
diarrhoea in children (Sydenham), husky voice, enlarged cervical 
glands and often parotitis, are present. This type is severe from the 
onset and the prognosis depends upon the number of pustules upon the 
face. Sydenham says that "if upon the face they are as thick as sand, 
it is no advantage to have them few and far between upon the body." 
Death occurs from acute toxaemia (variola typhosa seu adynamic a) , 
with hyperpyrexia and cardiac asthenia, or, if the patient lives longer, 
from septicopyemia, phlegmon, erysipelas, gangrene, pneumonia, 
pleurisy, and nephritis. Recovery from variola confluens is infrequent; 
in convalescent cases permanent deformity, such as ectropion, is prob- 
able. These cases run a course of three or more weeks. 

3. Purpura Variolosa. — This is the black smallpox — smallpox with 
primary hemorrhage in the initial stages. It is the worst type, and 
results almost uniformly in early death. It was frequent in the great 
pandemic of 1870-72. It is also important because of the difficulty in 
its diagnosis. It is seen most frequently in the unvaccinated, but may 
occur in the vaccinated, in women during the puerperium, in the young, 
and in robust males. The incubation is short (six to eight days), the 
invasion is stormy, with agonizing lumbar pain, great prostration, a 
rapid, small, soft, and sometimes dicrotic or irregular pulse, and 
disproportionately increased respiration. The initial epigastric pain 
and vomiting may last until death. 

On the second day (or even on the first), there appears a dark scarlet 
or plum-colored eruption, with brick-red, purple, or inky ecchymoses, 
which appear especially about the eyes. The aspect of the discolored 
and swollen face, and ecchymotic, sunken and intelligent eyes, is des- 
perate. Hematuria is the most common of internal or visceral hemor- 
rhages. Other forms are: Hematemesis, enterorrhagia, epistaxis, 
metrorrhagia, and hemorrhage from the gums, ears, and bronchi, 
sometimes accompanied by gangrene of the pharynx. Tympanites 
and genuine albuminuria may be noted. Miscarriage is frequent. The 
spleen is not enlarged. The disease does not usually reach the real erup- 
tion of variola, or, at the most, only the papules are observed, because, 
as Rhazes observed, the course is almost invariably fatal in four or five 
days. The mind often remains lucid to the end. In the majority of 
cases the fever is not high, but in the most fulminant type it reaches 
105° or 106°, with delirium, collapse, and coma. Death results in a few 
hours, even before cutaneous hemorrhage is seen, although internal 
hemorrhages are found at autopsy. According to Unna, the "blood 
dissolution" of the older writers is a mycotic coagulation thrombosis. 

4. Variola Pustulosa Hemorrhagica. — This is more common than 
Purpura Variolosa (primary hemorrhage). In this type of smallpox 
hemorrhage occurs after the eruption appears (secondary hemorrhage). 
This form occurs in weakly or alcoholic subjects. The initial stage is 
severe, and secondary hemorrhages occur into the vesicles or pustules, 
or into the lower parts of the body if the delirious patient has left his 
bed, or there may be "blood dissolution," epistaxis, hematuria, and 



72 THE SPECIFIC INFECTIONS 

metrorrhagia. Adynamic manifestations are usual, and the outcome 
is almost always fatal, though in one type, hemorrhage at the vesicular 
stage may be followed by rapid abortion of the rash and speedy recov- 
ery (Osier). 

5. Varioloid. — Varioloid {variola modificata s. mitigata, variolois) 
is variola mitigated by vaccination. The more marked the initial 
eruption, which is often morbilliform, the less the number of pustules. 
Varioloid begins suddenly. The fever is atypical. It may reach 103° 
and usually falls with the specific eruption, reaching normal on the 
fourth day. Secondary suppuration fever is rare and euphoria is 
common. The eruption is superficial, and, according to French clini- 
cians, there is no suppuration. The eruption varies in amount, being 
present on the trunk only, or being typical chiefly on the hands and 
feet. It may be absent entirely. It may not be umbilicated and may 
desiccate rapidly without rupture. The exanthem is usually small and 
scars are rare. The mucous surfaces are little involved, and are entirely 
unaffected. The entire course is shorter, more irregular, and rudi- 
mentary, and more benign than in variola vera. 

Complications and Sequelse. — The complications and sequelae of 
variola are many, occurring chiefly in the more severe forms and during 
the stage of suppuration. 

1. The Nervous System. — Nervous complications are very frequent. 
Delirium is caused by brain hyperemia, which results from swelling of 
the face and scalp (Curschmann) ; Jaccoud's types of nervous com- 
plications are (a) simple toxic, in nervous individuals, (b) alcoholic, (c) 
hyperpyretic. Convulsions are frequent in children. In adults they 
render the prognosis uncertain. Psychoses are usually asthenic 
(Kraepelin) and less frequent than they are after typhoid. Meningitis 
suppurativa is unusual and is seen most often in children (Gregory); 
encephalitis, aphasia in children, hemiplegia, embolism, cerebral soften- 
ing, phlebitis, and abscess, are occasional complications. Old writers, 
such as Trousseau, spoke of paraplegia, to which reference has already 
been made under backache. True motor paraplegia undoubtedly may 
occur, and also monoplegia, both caused by myelitis. Landry's paraly- 
sis has been recorded, as well as neuritis in the trunk and extremities, 
such as acute ataxia, or paralysis in the brachial, pharyngeal, oesopha- 
geal, bulbar, facial, and optic nerves. 

2. The Vascular System. — Vascular changes are more rare. The heart 
muscle may degenerate, becoming soft and relaxed, and microscopic- 
ally revealing segmentation, and cloudy and fatty conditions. Dilata- 
tion may occur. French writers speak of a coronary endarteritis and 
myocarditis (Desnos, Huchard). A systolic bruit may be heard at the 
apex, with weak first tone, and tachycardia, as is the case in typhoid. 
Aortitis with brain embolism (Potain) has been noted. Pericarditis and 
ulcerative endocarditis are rare. Marantic thrombosis occurs occa- 
sionally. 

3. The Respiratory Tract. — (Edema of the larynx and perichon- 
dritis are usually fatal, for laryngeal anaesthesia promotes inhalation 



SMALLPOX AND VARIOLA. VACCINATIOhJ 73 

pneumonia. Obstruction of the larynx by submucous hemorrhage is 
an uncommon complication. Bronchitis is invariable in severe cases. 
Pneumonia, usually lobular, occurs in 40 to 100 per cent, of fatal 
cases (confluent and hemorrhagic variola); lobar pneumonia is rare. 
Lung abscess, embolism, and gangrene, are uncommon. Pleurisy is 
present in some epidemics, is quite common according to Quinquad, 
occurs chiefly in the stage of suppuration, and is especially and rapidly 
fatal in children (E. Smith). 

4. The Digestive System. — Glossitis is rare and is observed chiefly 
in smallpox of the confluent type. Retropharyngeal abscess, gan- 
grene, parotitis, noma, phlegmonous oesophagitis, and hemorrhage, 
or membrane formation in the throat, are ominous though uncommon 
complications. The early vomiting rarely persists. Diarrhoea is not 
common, but a simple form is seen in children (Trousseau, Syden- 
ham), and a dysenteric form is occasionally seen in adults. Peri- 
tonitis and perineal abscess are infrequent. The alimentary tract, 
with the exception of the rectum, is usually considered exempt from 
the eruption. Isolated cases of retroperitoneal cellulitis and medi- 
astinitis occur. The liver may suffer cloudy or fatty change, focal 
necrosis, or diffuse hepatitis. The spleen is usually swollen and soft; 
but is sometimes firm and hard. 

5. The Genito-urinary Tract. — This is not often involved. Al- 
buminuria may occur early (Trousseau) in 25 to 33 per cent, of the 
cases. It may also occur during the eruption (Jaccoud), during sup- 
puration, or in convalescence (Cartaz, Bourgin, 2 to 10 per cent.). 
Nephritis is not frequent, but may develop during the fever or in 
convalescence; it is often glomerular. Focal necrosis may be noted. 
Pyelitis from cystitis or myelitis, diabetes mellitus, ovaritis, and vul- 
var gangrene, have been observed. Menorrhagia is common in the 
early stages of onset or in hemorrhagic forms, and abortion from 
hemorrhagic endometritis is the rule in pregnant women. Orchitis 
variolosa (Trousseau, Chiari, Velpaux), is very frequent, the inflam- 
matory foci being multiple. They lie mostly in the connective tissue, 
but are rarely suppurative, or associated with focal necrosis. 

6. The Special Senses. — The eye is involved in 1 per cent. (Hebra). 
Pox in the conjunctiva are rare, as are conjunctivitis, keratitis, diph- 
theria of the conjunctiva, iridochoroiditis, neuroretinitis, metastatic 
panophthalmitis, and retinal hemorrhage. Otitis, mastoid caries, and 
suppurative thrombophlebitis, may occur. 

7. The Locomotor System. — Muscular abscess or hemorrhage and 
arthritis, especially in the knee and shoulder, may occur during desic- 
cation. Arthritis is more often suppurative than serous, and is a 
feature of the secondary sepsis. In the bones there are almost invar- 
iably hemorrhage into the marrow, hyperplasia of the marrow cells, 
and multiple foci of necrosis or nonsuppurative osteomyelitis (in 72 
per cent, of the cases [Chiari] ). 

8. The Skin. — Decubitus, erysipelas, phlegmon, furuncles, ab- 
scesses (local or pyemic), post-variolous eruptions, erythema, pus- 



74 THE SPECIFIC IXFECTIOXS 

tules, impetigo contagiosa, bullae, great desquamation, acute gangrene 
(especially of the scrotum, and usually fatal), may develop in severe 
cases. In purpura variola, superficial hemorrhages occur in the skin 
in addition to subcutaneous hemorrhagic infiltration. Hemorrhage 
into existing exudates, and less often hemorrhage in the heart, spleen, 
kidney, liver, stomach, intestines, cellular tissue of the thoracic and 
abdominal cavities, braiu, and spine, also occur. 

Diagnosis. — The diagnosis of smallpox is usually easy when chill, 
fever, headache, backache, and vomiting, occur in the presence of an 
epidemic or after exposure to infection. Vaccination and revaccina- 
tion are factors and their scars must be searched for. It is often im- 
possible to avoid mistakes in the diagnosis of the first cases of an 
epidemic. In abortive or purpuric cases a diagnosis is also difficult 
or impossible. Hemorrhagic scarlatina or measles sometimes cause 
difficulty. In the former the mucous hemorrhages are less frequent 
than in smallpox. Differentiation between smallpox and virulent hem- 
orrhagic or fulminating purpura may be difficult. The initial sug- 
gestive scarlatiniform eruption is important but it has been unduly 
emphasized; the prodromal eruptions plus purpura are highly sug- 
gestive. Exposure to infection followed by an acute onset and high 
temperature is significant, although acute onset and high fever may 
occur in typhus (chill, macular and petechial rash, especially on the 
body, and persistently high fever), in pneumonia (chill, vomiting, 
herpes, pain in the chest, and rusty sputum), in scarlatina and 
influenza, with an initial rash, and in meningitis (joint involvement, 
headache, or vomiting). Lumbar and sacral pain is more common in 
smallpox than in typhus fever, pneumonia, or scarlatina. Intense 
frontal headache, severe backache, vomiting, chill, and fever, are suf- 
ficient grounds for a tentative diagnosis, and are important enough to 
necessitate isolation. Nevertheless, the diagnosis is uncertain until 
the eruption is seen. In the variola sine exanthemate (the febris vari- 
olosa of Rhazes and Sydenham, the variola sine variolois of de Haen, 
the varioles frustes of Costes) the diagnosis must be made from the 
history of exposure, the presence of an epidemic, fever, pain, delirium, 
possibly the initialr ash, (Sydenham, Frank, de Haen,) and the ab- 
sence of secondary fever because there is no suppuration. An eruption 
which appears on the third day of the affection, accompanied by a 
fall of the fever and euphoria, is most important. 

Vaeicella vs . Variola. 

Etiology different. Vaccination and Smallpox may closely resemble chicken- 
smallpox do not protect. pox (epidemic of Lee); very mild cases 

are especially misleading. 

Age: is not distinctively differential; Usually after puberty, with numerous 
varicella usually occurs before pu- exceptions, 

berty; it may occur in adults. 

An initial stage is practically absent. It is severe, even in mild cases. 

(Concluded on next page.) 



SMALLPOX AND VARIOLA. VACCINATION 



75 



Varicella 

Temperature: no remission with out- 
break of rash. 

Prodromal rash: very exceptional. 

Vesicles and roseolae (maculae) occur in 
crops and are simultaneous; very 
rarely shotty. 

Rash evolution: is much more rapid; 
vesicles in the first or second day. 

Eruption is universal, although succes- 
sive crops may occur; most abundant 
and characteristic (denied by Thomas) 
on back; begins on body; less on face, 
hairy scalp, mucosas, hands, and feet. 

The vesicle is superficial, and the trans- 
parent fluid shines through. (Wyss 
has observed confluent eruption and 
umbilication). 

Areola (halo) is usually absent. 

Involution is rapid. 



-Variola. 



Typical remission with secondary fever 
(except in varioloid). 

Frequent (10 to 16 per cent.). 

Never in crops; first macules, then 
hard, shotty papules, followed by 
vesicles, etc. 

Much slower; vesiculation on the sev- 
enth day (see Pfeiffer's table). 

Note place of first development; de- 
velopment progresses downward — 
face first, then hands and feet; less on 
trunk. 



The fluid is pearl-colored, not transpar- 
ent, and has a thicker covering. 



Marked. 
Tardy. 



Mistakes may occur among smallpox experts, but attention to the 
history, somatic findings, and course, rather than to the eruption, pre- 
vents many disastrous results. 



Measles- 



-Variola. 



Both present the same prodromal duration; in each the eruption begins on the face; 
according to some observers, simultaneously on face and trunk. 



Age: eminently a childhood affection. 
Catarrhal stage characteristic. 

Fever: present in catarrhal stage, but 
low before exanthem, and rises with 
its appearance 

Exanthem: Koplick's spots on buccal 
and labial mucosa; bluish- white sur- 
rounded by red. 

Eruption later with rise of fever. 

Papules "grouped," crescentic. 

Papules remain relatively flat, smooth, 
velvety. 

Grisolle's sign absent (the eruption dis- 
appearing under pressure). 

Areola (halo) absent. 



Chiefly in adults. 

Catarrh present, if at all, in rudimentary 
form. 

High before eruption, and falls with 
fiorition of the exanthem even in 
severe cases. 

Absent. Early papular eruption on 
palate, etc. 



Initial morbilliform eruption with the 
primary fever. 

Never so. 

Change into vesicles, pustules, crusts, 
scars; hard and shotty. 

Grisolle's sign present; i. e., persistence 
in smallpox of the papule on stretch- 
ing the skin, which distinguishes its 
eruption from scarlatina, varicella, etc. 

"Halo" present. 



76 THE SPECIFIC IXFECTIOXS 

Scarlatina vs . Variola. 

Rash on the second day, angina, straw- Rash later; slow evolution of different 
berry tongue, desquamation, glands, phases. No angina (or late, at least), 

nephritis, etc. (See cardinal symp- no glands, no strawberry tongue; 

toms of scarlet fever) . the initial scarlatinal eruption is not 

punctate, less extensive and bright, 
and does not desquamate. 

No double elevation of fever-curve. Double summit to curve. 

In drug rashes (copaiba, etc.), the pustules occur largely on the 
face, head, arms, and forearms, and much less frequently upon the 
trunk or legs. In syphilis the initial lesion, the glands, the polymorph- 
ism of the rash, and the absence of fever, or its presence in moder- 
ate form, are easily distinctive. 

The lumbago form of acute nephritis (Robin), acute myelitis or 
rheumatism, erythema, menstrual rashes, septicemic rashes, acne 
(cachectic and vulgar), and lichen, only superficially resemble variola. 

Glanders may cause more difficulty in making a diagnosis. Its 
features are malaise, pyrexia, pains, papules, pustules, nasal dis- 
charge, considerable exudation, and the proper bacteriological find- 
ings. Its general symptoms are more severe than the degree of skin 
eruption would indicate. 

Prognosis. — The prognosis depends on (a) previous vaccination, 
the disease being very fatal (40 to 50 per cent, mortality) in those un- 
protected by vaccination and revaccination. Smallpox is rarely fatal 
in persons who have been vaccinated within five or six years; only 
8 per cent, of those vaccinated once, die and only 4 per cent, of those 
vaccinated twice, (b) On the genius epidemicus: In our last epi- 
demic the death rate was but 3 per cent, (c) On the type, being (i) 
practically 100 per cent, in purpura variolosa; (ii) nearly 100 per cent, 
in variola pustulosa hemorrhagica; (iii) 60 per cent, in variola con- 
fluens — especially fatal in the first decade of life; (iv) 25 per cent. 
(15 to 35 per cent.) in variola discreta, — particularly dangerous in 
those over fifty or under ten years, in pregnancy, in the puerperium, 
in weakly and in alcoholic subjects; (v) 1 percent, in varioloid; (vi) 
recovery usual in variola sine exanthemate. 

The prognosis also depends upon individual symptoms: 1. In- 
cubation is short in unfavorable forms, especially in purpura variolosa. 

2. Initial symptoms are mild, chiefly in varioloid, but may be 
severe in both the benignant and malignant forms. Very severe head- 
ache indicates the hemorrhagic form. 

3. The initial rash is usually a partial erythema in mild forms 
of smallpox; and, in general, morbilliform eruptions occur in vario- 
loid. Scarlatiniform eruptions occur in rather severe forms, and a 
universal scarlatinal hemorrhagic eruption, especially in the groins, 
occurs particularly in purpuric types. 

4. The danger is proportionate to the amount of the eruption on 
the face and hands (Sydenham). A slow typical exanthem indicates 
variola discreta, and a precipitate atypical eruption is a symptom of 
variola confluens. 



SMALLPOX AND VARIOLA. VACCINATION 77 

5. A prompt fall in temperature after the eruption is favorable. 
A slow, complete fall occurs chiefly in the severe forms. Persistent 
apyrexia after florition and early desiccation indicate a mild type. 
Accession of fever after pustulation is ominous (Rhazes). There are 
fewer complications with an early fall of temperature. Hyperpyrexia 
or temperature collapse during suppuration is a sign of imminent 
death. 

6. In the stage of suppuration the danger is parallel to the height 
of the fever and the amount of cutaneous and mucous efflorescence. 
Enlargement of the spleen is ominous. 

Treatment. — I. Prophylactic Vaccination. — Protection from small- 
pox by cowpox vaccination was discovered by Jenner, who published 
his results in 1798, although he was practically certain of his evidence 
twenty years earlier! The idea had been long prevalent among farm- 
ers that cowpox afforded immunity to smallpox. Professor Water- 
house, of Harvard, in 1800, introduced vaccination into this country, 
and, among others, President Jefferson was instrumental in dissemi- 
nating its practice. 

The nature of cowpox, or vaccinia, is still bitterly disputed. The 
most probable view is that cowpox and horsepox are human small- 
pox modified by transmission through animals. Copeman suggests 
that vaccinia and variola have descended from a common stock. 
Variola inoculated in the cow produces typical vaccinia.. The other 
view, held largely by the French, is based upon Chauveau's experi- 
ments, which conclude that the two affections are distinct. The bac- 
teriology of vaccinia is also uncertain. Micrococci (Quist, Martin, 
and Ernst), bacilli (Klein and Copeman), and amcebse (Guarnieri's 
cytorytes vaccinia, Pfeiffer, Ruffer, and Reed), have been found. 

Usual Symptoms. — The incubation period is three days, during 
which there may be slight traumatic local reaction. The eruption 
occurs on the third day as a hard papule surrounded by a delicate 
halo. The papule enlarges, and on the fifth (or sixth) day shows 
Jenner's vesicle filled with clear serum, and umbilicated in the centre. 
It merges peripherally into the already indurated and painful skin, 
in which, by the eighth day, the magnifying lens shows many minute 
vesicles. By the tenth day, the serum of the vesicle has become puru- 
lent and the surrounding tissues are very hard and painful. By the 
eleventh day, a small central crust appears, which, by the end of the 
second week, covers the entire vesicle and is accompanied by a reces- 
sion of the adjacent cellulitis. In one or two weeks, the ulceration, 
decrustation, and granulation, are usually complete, and a scar or pit 
remains, which pales with time. Constitutional reaction is greatest in 
children. The fever in most cases appears on the fifth day, and some- 
times lasts four or five days, with leukocytosis, restlessness, headache, 
or backache. A swelling, depending on the site of inoculation, occurs 
in the axillary or inguinal glands. 

Unusual Symptoms. — The vesicles may develop early and run a 
course which may be shorter bv half than the usual one. Crusts 



78 THE SPECIFIC INFECTIONS 

may form in a week. In other cases the eruption may be tardy and 
atypical. In both instances revaccination is indicated. The eruption 
may recur as many as four times (Sutton), and in rare cases may be 
hemorrhagic, or even fatal. 

Complications. — These are rarely fatal. In Germany, in 1895, two 
deaths (from erysipelas) occurred in two and a half million vaccina- 
tions. To offset this theoretical risk there is the almost universal 
susceptibility to smallpox in all unvaccinated individuals. (1) Ery- 
thema, urticaria, roseola?, or erysipelas (third to eighth day). 
(2) Accessory vaccinia near the original inoculation, or generalized 
vaccinia, which develops about the eighth day on the trunk or extrem- 
ities, and often on the wrists; bullous or miliary vesicles sometimes 
continue to develop for over a month, and in weakly subjects are very 
exceptionally fatal. (3) Secondary infection in the first week or two, 
either local (deep ulceration, gangrene, lymphangitis, or lymphadenitis), 
or systemic (sepsis, pericarditis, meningitis, and parotitis). Very few 
cases of tetanus have occurred; McFarland (1903) collected 68 cer- 
tain cases, the majority of which occurred in Philadelphia. Albumin- 
uria is infrequent. (4) Later infections, such as tuberculosis or 
syphilis. Tuberculosis is but seldom inoculated, because it is 
rare in calves. Its inoculation can easily be prevented by the Belgian 
method of not using the lymph until the animal has been killed and 
found healthy. In some cases a latent tuberculosis in the patient 
may be awakened by vaccination, which seems to act like tuberculin. 
The danger of inoculating syphilis is far less now than when human 
virus was used. Fifteen days are necessary for the development of 
a chancre, and after about eight weeks more the secondaries appear. 
These are the chief diagnostic criteria. Syphilis may be inoculated 
accidentally and also intentionally, as in the oft-cited case of Dr. 
Cory. In exceptional cases syphilis already in the system may be 
aroused by vaccination. There are no clear cases of inoculation of 
leprosy. 

Age. — Children should be vaccinated in the third or fourth month, 
and it should never be delayed beyond the first year. 

Technique. — The arm (or leg, in the case of girls), should be washed, 
but no antiseptics should be employed, lest they neutralize the virus. 
A fold of skin should be raised and either rubbed with a piece of 
sterile gauze or scraped with a knife held almost parallel to the skin, 
until the epidermis is removed and slight oozing of lymph appears. 
The virus must reach the lvmoh stream, and therefore blood should 
not be drawn, as coagulation somewhat inhibits "taking." The vac- 
cine should be slowly rubbed over and into the abraded skin. The 
spot should be covered with a sterile dressing or cloth held in place 
by adhesive plaster, only after the virus has thoroughly dried. Boric, 
carbolic, or bichloride gauze must not be used. 

Lymph. — Vaccinia virus is harmless if it is pure and has been col- 
lected in the vesicular and not in the pustular stage. It can best be 
preserved in the fluid form, in sealed sterile tubes with three or four 



SMALLPOX AND VARIOLA. VACCINATION 79 

parts of glycerin. This obviates pyogenic infection, preserves the virus 
longer (four months), and is more economical than any other method; 
as twenty to twenty-five times as many vaccinations are possible with 
the same amount of virus when preserved by this method. When 
human virus must be used it should be taken from a perfectly sound 
child which has been carefully examined for tuberculosis and syphilis. 
It should be taken from the clear and unbroken vaccinia vesicle on 
the seventh or eighth day. No blood should be withdrawn, and the 
vesicle must be free from pus. 

Results. — The successful vaccination, accompanied by typical papu- 
lation, vesiculation, pustulation, crustation, cicatrization, and by local 
and often general reaction, confers immunity in almost all cases, 
though there are isolated instances when variola has closely followed 
successful vaccination. Although immunity is not absolutely infal- 
lible, vaccination is the greatest triumph of prophylaxis yet achieved. 
Immunity is not as a rule life-long, as Jenner thought. In some few 
cases, the individual is permanently protected by one vaccination, and 
revaccination is unsuccessful. Protection lasts on an average ten 
years, after which 60 (or 90) per cent, can be once or twice revac- 
cinated. Conversely, the child should be revaccinated in his tenth 
to twelfth year, and if the vaccination does not "take," it should be 
repeated. The reaction, fever, induration, and size of the vesicle and 
scar, are less in revaccination. It is also held that immunity is more 
certain and enduring when more than one inoculation has been made; 
the Germans, especially, vaccinate two areas, and, sometimes, even four 
or six. The nature of the immunity conferred is still disputed, but, 
unlike the immunity of diphtheria, it is probably due to actual tissue 
change. Pfeiffer advances the idea that in smallpox the germ endures 
in the tissues, and in this way maintains the usually permanent im- 
munity. Vaccination immediately after exposure is also thought to 
prevent or modify an impending attack. Partial immunity is evi- 
denced by mild varioloid (smallpox mitigated by vaccination). The 
general beneficence of vaccination needs no multiplied statistics. In 
general, epidemics prevail in communities which are least protected, 
and conversely, they disappear with systematic compulsory vaccina- 
tion, as was the case in the German army. 

II. Other Methods of Prophylaxis. — Isolation hospitals and sta- 
tions are indispensable, because smallpox patients are infectious in all 
stages of the disease. Isolation is necessary from the incipiency until 
the disappearance of the last crust. The dead body is dangerous and 
the funeral must not be public. The clothes used by the patient must 
be steamed, and other articles must be washed with bichloride of 
mercury and fumigated with formaldehyde vapor; Schoch's method 
has the advantages of not requiring any special form of apparatus, 
of cheapness, and freedom from danger of fire. The following are 
required: good quicklime in lumps, commercial sulphuric acid, and 
ordinary 40-per-cent. formaldehyde solution. For every 1,000 cubic 
feet of space one pound of formaldehyde solution, one-half pound 



80 THE SPECIFIC INFECTIONS 

of sulphuric acid, and three pounds of quicklime are required. The 
acid and the formaldehyde are first mixed in an earthenware vessel 
by pouring the acid into the formaldehyde. Then the lime is placed 
in a shallow vessel in the centre of the room. All openings to the 
room are carefully closed, the mixture is poured on the quicklime, 
and the operator leaves the room. The rooms should remain closed 
for from five to eight hours. Disinfection of the face, hands, beard, 
and hair of attendants by bichloride solution is imperative. The 
family should be isolated for sixteen to twenty days. 

III. Actual Treatment. — As Jaccoud early announced, there is no 
specific treatment for smallpox. Its hygiene and dietary are the same 
as in typhoid. For headache, the ice-bag, opium, and hydrotherapy 
should be resorted to. Pain is relieved by opiates. 

The initial vomiting is difficult to overcome, but its duration is for- 
tunately short Ice-pills, lime-water, iodine, chloroform, morphia, car- 
bolic acid, and bismuth, may be used as they are in typhoid, but mustard 
plasters should never be applied lest they initiate necrosis of the skin. 

Early hydrotherapy is important in giving relief from fever. It 
lessens the dermatitis, though later, when the rash has developed, 
baths are contraindicated. 

Delirium may be relieved by hydrotherapy, by chloral, bromides, 
hyoscine, and morphia. The latter, in half-grain doses, is invaluable 
as a routine treatment, since it lessens itching and pain and conserves 
metabolism. There is great danger that the patient, if delirious, may 
escape, injure himself, or commit suicide. Dr. NcNamara, a class- 
mate of the author, killed himself by jumping through a window 
which had been carelessly left open near him. Patients should never 
be confined by straps, for this may cause serious skin trouble (necro- 
sis). It is better to dress them, or even walk them up and down the 
room. 

The eruption may be pricked and cauterized with silver nitrate 
(Arabian method), treated with bichloride or boric compresses (Hebra), 
covered with mercurial plaster, or with 1-per-cent. carbolic acid and 
vaseline salve. The latter is the best, because it counteracts the par- 
ticularly offensive odor. Carbolic salve should be used on the face 
only, since general use over the body may cause carbolic-acid poison- 
ing. These measures are not specific nor do they prevent cicatrix 
formation, but they relieve dermatitis and itching. Covering the face 
from the light with wet compresses seems to lessen the pitting. The 
crusts should be kept soft with olive oil. The hair should be cut 
short, and the eyes should be closely watched, and douched frequently 
with boric-acid solution. 

The mouth, the larynx, the circulation, and diarrhoea, should be 
treated as they are in typhoid fever. For bed-sores, a water-bag or 
-ring should be used. Sydenham allowed his patients to leave bed as 
soon as the fever declined. 

For sepsis, quinine (v. sepsis) and alcohol (v. typhoid) are given 
by the rectum, since dysphagia is always present. Eggnog properly 



CHICKENPOX 81 

prepared will not injure the throat. During convalescence the crusts 
should be carefully washed, and the patient may be considered safe 
only when the skin is clear of the last scab. 

CHICKENPOX (VARICELLA). 

Definition. — An acute specific febrile contagious disease, chiefly one 
of infancy and childhood, characterized by an exanthem of vesicles 
which usually appear in crops. 

History. — Varicella was recognized by Heberden in 1767, and by 
Trousseau, as a disease distinct from smallpox. It is still classified 
by the Hebra school as smallpox. 

Etiology. — It is transferable by direct inoculation, by personal con- 
tact, by the air, or by a third person. It is infective while crusts re- 
main. Epidemics of varicella may coincide with, precede, or follow, 
smallpox. Smallpox does not prevent an attack of varicella nor is 
the converse true. The disease occurs chiefly in epidemics, although 
sporadic cases are frequently seen. A second attack is rare. Season 
has no influence upon the appearance of the disease. It occurs chiefly 
in the first year of life, or, according to others, 66 per cent, of the cases 
occur between the years of two and six. It has never been observed 
congenitally, and some deny its existence in the adult, although such 
cases do occur. 

The actual cause is not determined. Bareggi described a peculiar 
coccus; Guttmann, the yellow and white staphylococcus; and PfeirFer 
and Guinon, a protozoon. It may occur with pertussis, morbilli, scar- 
latina, diphtheria, pneumonia, or smallpox. 

Symptomatology. — I. Incubation. — The stage of incubation, like 
that of measles, lasts thirteen or fourteen days (eight to nineteen 
days), or three to six days after inoculation. 

II. Stage of Prodromes. — Prodromal symptoms are generally 
rare. They are frequent in adults, according to Tordeus, and may 
be severe. If there are any prodromal symptoms, they last but twenty- 
four hours (Trousseau). Severe intoxication is rare, but the following 
have been observed: delirium, convulsions, violent vomiting, hyper- 
thermia, dyspnoea, angina, conjunctivitis, pale urine, tenesmus, dys- 
phagia, muscle pains, lassitude, intestinal irregularity, bloody vomiting 
and stools, and initial erythema (usually scarlatiniform, rarely morbil- 
liform, in the fifteen cases recorded). 

III. Stage of Eruption. — The exanthem sometimes appears suddenly 
after a slight chill, usually in the first twenty-four hours, as red 
macules or papules. They are comparable to the typhoid roseohw 
are slightly elevated, disappear on pressure, and are lenticular. Some 
regress, but most become vesicular in from six to twelve hours. The 
vesicles mature within a day. They are very superficial, and do not 
occupy the whole roseola, but leave a slight areola about them, which 
is hypersemic and not inflammatory as it is in smallpox. In some 



82 THE SPECIFIC INFECTIONS 

cases the areola may be absent, the eruption appearing like drops 
of water sprinkled on the skin. Though usually discrete, Wyss and 
Immermann describe confluent eruptions. The vesicles may be few 
or quite numerous; Thomas counted 800 in one of his cases. In 
shape, the eruption is mostly elliptical or circular. Rare forms are 
reported with jagged, sinuous edges, when the vesicle overlaps the skin. 
In size, the vesicles may be very large, and, in exceptional cases, re- 
semble pemphigus; they are alleged to have attained a size of four 
centimeters. 

The eruption begins on the trunk, back, and chest (Osier, Guersaut, 
Blache); on the face, temples, forehead (Eichhorst, Immermann), 
and, according to Thomas, rarely fails to appear on the scalp. Trous- 
seau held that there is no point of predilection for the eruption. Henoch 
finds it often on the part on which the patient lies or where irritation 
exists. No part can be considered exempt, though most vesicles ap- 
pear on the trunk, fewer on the face, arms and legs, and the least 
number upon the hands and feet. The eruption is sometimes grouped, 
as it is in herpes zoster. 

The contents of the vesicle are usually clear at first, and become 
turbid in thirty-six to forty-eight hours ; neutral or alkaline, and never 
acid. Pustulation may occur (Leube), though this is denied by some. 
Hemorrhage rarely occurs into the vesicle. The vesicle may contain 
air after rupture. Umbilication, though rare, may occur (Wyss). 
Eichhorst denies the statement made by Goruall that the umiblica- 
tion of variola exists from the beginning of the eruption, while that 
of varicella occurs late. Crusts may simulate umbilication. That the 
vesicles of varicella are always unilocular is also denied. 

Occurrence in crops is frequently observed; the skin then shows 
simultaneously macules, vesicles, and crusts. Yellowish-brown crusts 
form on the third and fourth days and gradually disappear, leaving 
a somewhat flattened epidermis, which may desquamate slightly. 
Distinct scars are rare, but may result from scratching or infection, 
especially on the body or on the face. A few cicatrices are usual in 
almost every case of varicella (Guinon), but they are smooth, white, 
and some of them disappear with time. 

Enanthems are not frequent. Vesicles are sometimes seen on the 
palate but may easily be overlooked. Breaking down, they resemble 
aphthae. They may precede the exanthem. On rare occasions they 
are seen on the tongue, cheek, nose, larynx, external ear, prepuce, 
or labia. 

Fever. — The fever is slight, if indeed there be any. It is atypical 
and is not parallel to the eruption. Fever as high as 106.8° is recorded 
by Thomas. It is very rarely present in the prodromal stage, but 
may occur with profuse eruptions, or with successive crops; its per- 
sistence suggests complications. 

General Symptoms. — These are few, but sometimes include dys- 
phagia, cervical and submaxillary swellings, tracheitis, bronchitis, 
albuminuria, or acetonuria. 



SCARLET FEVER 83 

The entire course of an uncomplicated case lasts from one to two 
weeks. 

Complications and Sequels. — These are usually dismissed with a few 
words. Nephritis, first described by Henoch and since by Vichmann, 
Unger, Janssen, and others, is generally mild, tubular, and occurs from 
three to fourteen days after the rash declines. Though it is usually 
mild, numbers of fatal cases have been lately reported as well as some 
which have resulted in chronic nephritis, cardiac hypertrophy, and 
uraemia. Gangrene of the skin, seen especially in delicate or tuber- 
culous children, and first described by J. Hutchinson, may occur in 
the extremities, scrotum, or eye-lids. Pneumonia is rare. Other com- 
plications which are infrequent, are abscess of the lung, pleurisy, acute 
miliary tuberculosis, erysipelas, sores in the skin which may lead to 
tuberculosis, glandular swelling, pemphigus, infantile hemiplegia, 
osteitis, measles, scarlatina, synovitis, simple or suppurative polyarth- 
ritis, peritonitis, otitis media, neuritis, spasm of the larynx, suffoca- 
tive laryngitis, and the persistence of an unmanagable mixed papular 
and vesicular eruption on the palms of the hands and soles of the 
feet. 

Diagnosis. — The diagnosis is very easy if the case is seen early. 
Differentiation from smallpox has been considered. There is usually 
no fever, the eruption is more vesicular, without halo, larger, but less 
in number than in smallpox. In pemphigus the vesicles are larger 
and run a slower course of weeks or months. Miliaria rubra are pre- 
ceded by sweats, occur chiefly on the covered parts, have acid con- 
tents, are smaller than the varicellous eruption and disappear more 
rapidly. Sometimes consideration must be given to molluscum con- 
tagiosum (soft, umbilicated tumors with white granular contents); 
prurigo varicelliformis (with crop-like eruptions at longer intervals); 
eczema vesiculosum, which always occurs with great itching; herpes,, 
always appearing in groups and often along nerve-trunks; varicella? 
syphilitica?, and medicinal rashes from cantharides, bromide, arsenic, 
and iodide. 

Treatment. — Active treatment is rarely indicated. 



SCARLET FEVER (SCARLATINA). 

Definition. — A specific infective disease of unknown bacteriology, 
characterized by sudden onset, fever, diffuse exanthem, and angina. 

History. — It was recognized by Ingrasseas and Coyttar in the six- 
teenth century, but was first fully described by Sydenham (1660); 
before this, it was known as measles. Scarlatina was introduced into 
America in 1735. 

Etiology. — The etiology is unknown. Class described a diplo- 
coccus, but this has not been confirmed. Babes, Babinsky, Pearce, 
Wright, and others, have found a streptococcus in 58 per cent, of 
fatal cases, and, while their results in no way prove that it is the cause 



84 THE SPECIFIC INFECTIONS 

of scarlatina, it is probable that tthe streptococcus is the most impor- 
tant factor in the production of the complications and in their mor- 
tality, Hektoen, Weaver, and Ruediger, in 100 cases, found it in the 
blood in 12 per cent. Coinbinings everal statistics, the streptococcus as 
found in about 70 per cent, of the fatalities; i.e., it is the cause of the 
malignancy of the disease, but not of the disease itself. The organism 
is also found in diphtheria, measles, and variola. The virus of scarlet 
fever produces severe necrosis, but no suppuration. Mallory describes 
a protozoon, the cyclastcr scarlatinalis. 

Susceptibility is not universal; only 38 per cent, of children and 
5 per cent, of adults exposed to infection acquire the disease. Sus- 
ceptibility varies, also, from time to time in the same family. 

So-called surgical and puerperal scarlatina, noted in 1864, by Paget, 
are, in the vast majority of cases, sepsis, erythema congestivum, ery- 
thema toxicum, or drug rashes. Alice Hamilton (1905) collected 174 
cases from the literature, and concludes that these forms are mostly 
septic, and occasionally mere coincidents. 

The virus circulates in the blood, whence the possibility of foetal 
infection even though the mother may escape. The mother may con- 
tract the disease and the child may escape. It is usually held that 
the disease is probably not infectious before the eruption, and that 
the virus is especially active during desquamation. Aaser holds, and 
justly, that the throat secretions are most dangerous. The strepto- 
cocci may be spread by coughing (Hamilton). Infection is often 
spread even two months or more after desquamation is complete. 
In no other disease is the virus so tenacious; it may persist as long 
as ten years in clothes, furniture, and on the walls. Light forms are 
as contagious as severe ones. Inoculations, from the living subject 
and from the cadaver, have occurred. Leube acquired the disease by 
a cut during an autopsy upon a scarlatina case. The entrance is 
not known; but it is probably through the throat. 

Infection may be spread by servants, by physicians, by any third 
person, and by means of toys, books, clothes, and milk, and in schools; 
but the mode of infection is often unknown. One attack usually con- 
fers immunity, but second, and even third, attacks are known. In 
some individuals there appears to be a temporary or permanent im- 
munity. Scarlet fever occurs at all seasons, but probably more often 
in the autumn and winter. Scarlatina is observed more in the cities, 
and measles prevails more diffusely through the country. Scarlatina 
is more permanent than measles. When it becomes epidemic it is 
likely to spread widely, and usually has a mortality increased three- 
or even thirty fold. 

Ninety per cent, of cases occur under ten years of age (Murchison), 
although adults are not exempt. It is rare in the first year of life. 
The sexes are equally involved. 

Scarlatina sometimes occurs with other infections, such as diph- 
theria or measles, and less often with variola, varicella, herpes, mumps, 
pertussis, erysipelas, or typhoid. 



SCARLET FEVER 85 

General Symptomatology. — 1. The Stadium Incubationis. — The 
incubation, with no noticeable symptoms except perhaps anorexia or 
slight depression, lasts from two to four days, though sometimes one 
to seven days. 

2. The Stadium Invasionis. — The invasion lasts one day. Symp- 
toms begin suddenly, with perhaps a chill. This is followed by (a) 
headache, dulness, convulsions, and delirium; (b) vomiting, early 
and characteristic, which occurs in scarlatina more often than in 
other diseases of childhood except pneumonia; (c) sudden elevation 
of temperature, even to 105°, with disproportionate pulse-rate, 120 
to 150, with dry, burning skin, and febrile urine; (d) dryness, red- 
ness, burning, pain in the throat, dysphagia, and intumescence of the 
cervical glands. 

3. The Stadium Exanthematicum. — The exanthem lasts four to 
six days. It appears on the second day, first below the clav- 
icles, on the upper trunk, and on the neck, then on the extrem- 
ities, and least on the face and scalp. The skin about the 
mouth is pale. The exanthem pales on pressure. It consists first 
of small red spots (swollen hair follicles), the size of a pin-head, 
which fuse as the skin swells, and result in an intense diffuse lobster- 
colored erythema. The .tongue swells, becomes covered with a gray- 
ish-yellow coating, is red on the tip and edges, and shows swollen 
red papilla? — " cat's tongue," or " strawberry tongue." Later the whole 
tongue becomes red and dry. On the tonsils and palate a grayish- 
yellow coating and confluent spots appear. The nostrils become 
slightly swollen, and redness of the conjunctiva? develops with secre- 
tion. Some rales over the larger bronchi, a slight cough, swelling of 
the cervical and other glands, and some albuminuria, may be noted. 

4. The Stadium Desquamationis. — The desquamation lasts several 
weeks, though the rash itself lasts but three to six days. Desquama- 
tion begins first on the face, from the sixth to ninth day. The 
glandular swelling disappears, the fever falls by lysis, and convales- 
cence is established unless complications intervene. 

Special Symptoms, Complications and Sequels. — These are given 
in detail because of the extreme variability in the clinical symptoms: 

1. The Fever. — The fever is less typical (Wunderlich) than in most 
exanthemata; e. g., smallpox and measles. In the invasion there is 
a rapid rise to 104° or 105°. The fever is usually somewhat higher 
on the second day, with slight morning remissions and gradual sub- 
sidence when the rash is mature. 

In the most severe types there may be low fever or no fever at all, 
or it may rise to 107° or 109°. We usually note a close parallelism 
between the abundance of the exanthem and the height of the fever. 
The temperature should be taken during one month after the rash, 
lest such complications as sloughing of the throat, pleuritis, endocar- 
ditis, pericarditis, synovitis, or adenitis be overlooked. A long course 
of fever may exceptionally occur without complications, but it is 
rather ominous. 



86 THE SPECIFIC INFECTIONS 

2. The Eruption. — The eruption is often atypical. Typically, it begins 
in the form of light-red, pin-head-like points which become darker 
as the skin swells and the eruption diffuses. It then appears as an 
even red, and on close inspection is found beset with small points. 
These are the first part of the exanthem to develop, and the last to go. 
The eruption, then, first consists of red spots, especially in the axilla 
and groin; second, of red spots in a diffuse erythema; and lastly, of 
red spots again. This minute papulation is a very important aid to 
diagnosis in the second week. There may be minimal white lines 
in the eruption, but rarely ever spaces as there are in measles. Fiir- 
binger compares the skin in measles to splashes of red paint, and in 
scarlatina to an even red coating. The skin is sometimes vesiculated. 
Though it spreads less regularly than in measles, the eruption appears 
first on the neck, below the mastoid process, and below the clavicles, 
then upon the head, trunk, arms, and hands, and lastly upon the legs 
and feet. It is most intense over the extensor surfaces of the joints 
and on the trunk, and is least developed on the face and scalp. The 
palms of the hands and soles of the feet are usually free. The pallor 
around the mouth contrasts vividly with the scarlet cheeks and mi- 
nutely papulated forehead. This pale area is circular or triangular, 
bounded by the nasolabial folds above and the chin below. Though 
not pathognomonic, it is always valuable in differentiation, and is 
due possibly to vascular spasm. The eruption is occasionally roseo- 
lous about the ankles and wrists. The skin is always swollen, usually 
pales on pressure, and sometimes itches, or is wet with sweat and is 
vesiculated. The eruption is hypersemic, and it therefore pales on 
pressure and disappears after death, unless there are punctate hemor- 
rhages, which are not uncommon in severe types of the disease. After 
twenty-four hours Of the eruption, the tension disappears, and the 
bright-red color becomes a yellowish-red. Pathological changes in 
the skin, according to Unna, consist of hyperemia, especially in the 
papillae, but rarely oedema, inflammation, or hemorrhage. After com- 
plete florition the skin becomes dry, and desquamation begins. This 
is usually bran-like as it is in measles, on the head, face, neck, and 
trunk, and it is more scale-like and lamellar on the hands and feet, 
complete casts of which are sometimes shed. The scales are often 
large in proportion to the intensity of the eruption. In severe cases 
even the hair and nails are shed, and the nails become furrowed. Des- 
quamation results from a slight exudation of serum between the layers 
of the skin. It begins on the cheek with the "rouge-and-powder" 
appearance, and is usually first observed when the fever and angina 
decline, but it may be delayed from two to seven days later. The 
skin may present a "pin-hole" or "worm-eaten" aspect before des- 
quamation begins. Its duration is most variable, usually lasting from 
one-half to three weeks, or even seven or eight weeks (Trousseau). 
Other occasional skin complications are : Bed-sores, gangrene, oedema 
(either with or without nephritis), and eczema on the face, scalp, or 
ears. This is usually impetiginous. Anomalies of eruption: Scar- 



SCARLET FEVER 87 

latina laevigata is the typical rash which has been described above. 
Other forms are scarlatina l&vis (rudimentary or localized eruption); 
scarlatina sine exanthemate (the rash being wholly absent); scar- 
latina papulosa (marked papulation); scarlatina miliaris (promoted 
by sweating, but also the result of exudation between the rete Mal- 
pighii and the epidermis); scarlatina variegata (like measles, though 
not equally elevated); scarlatina hemorrhagica (usually ominous, and 
at times part of a general hemorrhagic diathesis). In general, ir- 
regular forms are dangerous. 

3, The Throat. — The throat changes are the most constant lesions in 
scarlet fever, and constitute the internal eruption (enanthem). The 
disease begins in the throat with dryness, uniform redness, and in- 
variably with early swelling. The throat very soon becomes speckled 
with fine red points like the skin papulation. Though always present, 
it varies in intensity. All forms, from simple angina to diphtheritic 
or gangrenous inflammation, may be seen, (a) In mild cases, a simple 
catarrh with little swelling, a thick mucous coating, and more or less 
reddening of the palate and tonsils, develop. (6) In moderate cases, 
there is, in addition to the above, more swelling of the palate, and 
tonsillitis, (c) In severe cases, membrane, small abscesses, gangrene, 
small hemorrhages, sloughing, and, perhaps, sudden hemorrhage, 
oedema, adenitis, periadenitis, or cellulitis, develop. Severe inflamma- 
tion in the throat occurs in 65 per cent, of the cases (Von Ranke) . 

Clinical and anatomical diphtheria are often confused. " Necrotic 
inflammation" in scarlatina is that caused by the virus of scarlatina 
alone. Genuine diphtheria may accompany or follow scarlatina; of 
these, post-scarlatinal diphtheria is the more dangerous (Trousseau). 

Diphtheritic Membrane. vs. Scarlatinal Membrane. 

Firm, adherent. Softer, loosened in fragments. 

Yellow-gray. Brownish tint. 

Deep ulceration rarer, in more severe More frequent and earlier (even in 
cases only, and later. twenty-four hours). 

Phlegmon rare. Not infrequent. 

Laryngeal membrane (croup) frequent Rare, membrane thinner; lung com- 
and deeper. plications rare. 

Bacteriologically, the Klebs-Loeffler Streptococcus (Klebs-Loeffler bacillus 

bacillus. found only as a complication). 

Paralysis frequent. Rare, except local paralysis due to local 

swelling of pharynx. 

Recurrence frequent. Infrequent. 

Since the bacteriological cause of scarlatina is undetermined, it is 
doubtful whether the pyogenic cocci found in the throat are integral 
or complicating. 



88 THE SPECIFIC L\FECTIOXS 

4. The Respiratory Tract. — Though often unaffected, the respiratory 
tract may become secondarily involved by a descending process. The 
nose is involved in direct ratio to the severity of the throat develop- 
ments, such as necrosis, diphtheria, and gangrene. Acute oedema of 
the glottis is infrequent. The bronchial mucosa is more often in- 
volved than is usually recognized. Bronchopneumonia, acute lobar 
pneumonia (usually in the upper lobes and coexisting with nephritis), 
gangrene, infarcts, inflammatory oedema and hypostasis, are not com- 
mon. Pleurisy, described especially by R. P. Howard, occurs in 5 
per cent, of the cases. It is often overlooked, is likely to be severe, 
is very frequently purulent, and often occurs during convalescence. 

5. The Heart. — The heart may be greatly damaged by the scarlatinal 
virus, and is involved in 35 per cent, of the cases, not including the 
cases of sepsis and nephritis (Schmaltz). Endocarditis is frequently 
mural, whence its frequent latency, but it may result in chronic 
valvular disease, especially of the mitral valves. "After rheumatism, 
scarlatina is the most frequent cause of endocarditis" (Leube). 
Tachycardia may often be observed from toxaemia or acute infective 
myocarditis. With increased arterial tension due to kidney disease, 
the heart is slowed, and hypertrophy may result, unless pancarditis, 
(endo-, myo-, and pericarditis), exist. Pericarditis is usually septic, 
Disquieting cardiac dilatation may be seen in severe cases, accom- 
panied by the usual evidences of acute cardiac insufficiency; it may 
occur during the fever (Rhomberg), or in convalescence (Schmaltz). 
Dilatation and hypertrophy are much more frequent in children than 
in adults, and often complicate renal lesions. Leukocytosis develops 
early and may become extreme in. fatal cases. It has been recently 
stated that the leukocytes are normal in number, but the polymorpho- 
nuclears are absolutely and relatively increased two or three days 
after the eruption. The eosinophiles are also increased. The haemo- 
globin and red cells suffer an early and increasing reduction. The 
red cells average 4,000,000. Hemorrhagic diathesis seldom occurs 
except as a result of sepsis. 

6. The Digestive System. — The tongue is swollen, indented, 
broad, and thick. Its papillae become larger and separated from 
each other. Its coating is first grayish, and only the edges and 
tip of the tongue are reddish, but later the coating disappears, leav- 
ing the tongue very red, dry, and glistening, on which the papillae 
appear granular and warty — the " strawberry," "raspberry," or ''cat's 
tongue.'' This appears from the third to the fifth day and lasts a 
week. It is quite pathognomonic, according to Leube, and is only 
second in importance to the angina. McCollom, of Boston, found 
it the only constant sign in 1,000 cases of scarlatina. The breath may 
often be sweet and of a very heavy odor. Diphtheritic ulcers and 
secondary necrosis in the stomach, oesophagus, and intestines, have 
been found. Vomiting may result from nephritis, brain toxaemia, or 
coughing. The liver and spleen may be slightly swollen. There may 
be abdominal pain. Constipation is usual. Diarrhoea, however, may 



SCARLET FEVER 89 

result from (a) simple catarrhal enteritis, which is transitory and not 
unfavorable (Litten); (b) dysentery, with tenesmus and blood; (c) 
the so-called "scarlet-typhoid" of Thomas, which is accompanied by 
tympany, hemorrhage, fluid faeces, very rapid pulse (herein differing 
from typhoid), and lethal outcome. Its resemblance to typhoid is also 
heightened by the autopsy findings of splenic intumescence, and hy- 
perplasia with ulceration in Peyer's patches. 

7. The Kidneys. — The urine is febrile. It will respond to Ger- 
hardt's reaction and to the diazo test, though to a less degree than in 
measles. Increased phenol and beta-oxybutyric acid may be found. 
Albuminuria occurs in 77 to 92 per cent, of all cases. Early renal 
changes may occasionally be observed. The "initial catarrhal ne- 
phritis," which runs a short course, is accompanied anatomically by 
hypersemia, parenchymatous changes, some fluid in the glomeruli, a 
few cylinders in the tubules, and little interstitial involvement. 

Nephritis usually develops in the third week (ninth to fortieth day). 
Its frequency varies with the epidemic, between 5 and 70, or even 90 
per cent. No apparent relation exists between its frequency and the 
severity of the infection. No single anatomical form is invariable, but 
the glomerulonephritis of Klebs is most frequent. It is characterized 
anatomically by hyperemia, increased consistence, and such glomerular 
changes as gray color, diffuse fatty granular degeneration, increase of 
nuclei, and increase by 50 per cent, in the size of the tufts, which become 
sausage-like solid masses. We also note exudation of leukocytes about 
the afferent vessels, multiplication of capsular epithelium with occlu- 
sion of the lumen, hyaline alteration of the vessels, and small and early 
interstitial changes, and later connective-tissue growth. Friedlander 
observed septic interstitial nephritis and the large variegated kidney, 
in cases accompanied by diphtheria, or phlegmonous complications. 

Hydrops in the vast majority of cases is renal and shows the char- 
acters of renal dropsy. It appears first under the skin, and the cuta- 
neous blood- and lymph-vessels are altered by the virus. It shifts its 
location, varies without cause, and may produce hydrothorax, ascites, 
oedema of the larynx, of the lungs, or of the genitalia. The older 
writers claimed that hydrops occurred without nephritis, and that 
kidney inflammation might exist without appropriate urinary altera- 
tions. Such a view can be proved by autopsy only. The temperature 
is inconstant. There may be lumbar pain, vesical tenesmus, and 
ursemic symptoms, such as headache, twitchings, convulsions, wide 
pupils, amaurosis, disturbance in motility, in sensation, and in cere- 
bration, coma, involuntary evacuations, vomiting, diarrhoea, cardial- 
gia rapid pulse and breathing, and pale skin tinged with cyanosis. 
The retinas are usually normal. Many convulsions usually imply a 
lethal termination in coma. The prognosis is more favorable if the 
pupils are not immobile. The urine is decreased or suppressed, is 
heavy with sediment and albumin (averaging 0.5 per cent.), is poor 
in urea, turbid (specific gravity 1030), and is full of casts of all types — 
especially, long, flat, band-like, twisted, and frayed casts. Much ox- 



90 THE SPECIFIC IXFECTIOXS 

alic and uric acid is found and, in many cases, blood. Uraemia, hydrops, 
and intercurrent inflammation, are always dangerous. Convalescence 
is the rule after four to six weeks (eight to eighteen months), and the 
nephritis rarely becomes chronic. 

8. The Special Senses. — Decreased secretion in the eye is common. 
Cerebral complications promote inflammation in that the eyes close 
less frequently. Catarrhal conjunctivitis, diphtheritic inflammation, 
involvement of the lachrymal sacs, herpes or necrosis of the cornea, 
panophthalmitis, muscular paralysis, and disturbance in accommoda- 
tion, are possible complications. Ursemic amaurosis, neuroretinitis 
septica seu nephritica, and retinal hemorrhage, are rare. Middle-ear 
inflammation (11 to 33 per cent, of the cases) usually begins before 
desquamation, but may be observed later. It may easily be over- 
looked, and is accompanied by fever, pain, glandular swelling, difficult 
hearing, tinnitus, a reddened, glistening, sunken membrane, and, in 
children, by some brain manifestations. It is quite frequent in early 
life and rare after the fifteenth year; 10 percent, (even 42.6 per cent. !) 
of cases of acquired deafness are said to result from scarlatina. 

9. The Lymphatic System. — The lymphatic system is generally in- 
volved; e. g., glands, spleen, follicles, and in severe cases, all the 
lymphatic structures, are affected by the sepsis. The " collar of brawn " 
results from cervical adenitis and periadenitis. Gangrene, retroster- 
nal abscess, and jugular phlebitis with sepsis, occur in desperate cases. 
After recovery the neck may remain swollen for a long time. 

10. The Bones and Joints. — Scarlatinal "rheumatism" is found in 6 
(2 to 12) per cent, of the cases, usually in the second or third week 
(with desquamation and subsidence of the fever), and usually lasts 
three or four days. It attacks the smaller rather than the larger joints, 
the wrists rather than the elbows or shoulders, and the ankles rather 
than the knees. It develops with pain, and is not so migratory as 
ordinary rheumatism. It may leave no autopsy findings, or it may 
become purulent. Swelling of the joints does not always occur. It 
is claimed that swelling occurs in those who have had rheumatism, 
and that it may respond to salicylates. It occurs in old rather than in 
young subjects. Endocarditis follows in less than 3 per cent, of scar- 
latinal rheumatism. The prognosis is usually good. Bone involve- 
ment is rare. 

Scarlatinal sequels are ana?mia, hemorrhagic diathesis, retarded 
development, and decreased physiological resistance. Tuberculosis 
rarely follows scarlatina, because the two diseases are rather an- 
tagonistic. Latent sepsis with brain foci, valvular disease, chronic 
nephritis, chronic adenitis, otitis, mastoiditis, deafness, meningitis, hemi- 
plegia, cerebral venous thrombosis, facial paralysis, ascending spinal 
paralysis, chorea, and exhaustion psychoses, are fortunately the more 
rare complications and sequels. 

Diagnosis. — Typical cases are easily determined when an epidemic 
prevails, and when the eruption is not considered of chief diagnostic 
reliance. The criteria are as follows: 



SCARLET FEVER 91 

1. Sudden onset and rapid development, with fever and vomiting. 

2. Angina, pain, redness, punctate spots in vault of the mouthy 
swelling and dysphagia, which are practically always present. Severe 
symptoms in the throat, especially during an epidemic, are suspicious. 

3. Strawberry tongue, which is practically constant. 

4. Exanthem. This appears about the clavicles, and shows a char- 
acteristic progression. The face is less involved, and the mouth is 
free; it is intense on body; papules then erythema develop; there 
are no free spaces; it results in desquamation. 

5. Lymphadenitis. In this, the cervical are less important than 
the inguinal glands. 

6. Fever, hydrops, albuminuria, and nephritis, in atypical cases. 

7. Scaling, tender joints, and albuminuria, are strong indications of 
scarlatina if the initial symptoms were not observed or were not clear; 
they help in making a retrospective diagnosis. 

Diagnosis of Atypical Scarlatina. — 1. Severe scarlatina, (a) An- 
ginose form. This resembles septic diphtheria, with marked toxaemia, 
necrosis, and adenitis, (b) Atactic form. Violent early intoxication ; 
high fever and death even on the eleventh hour of the disease (Trous- 
seau), before the eruption appears; blood dissolution, vomiting, diar- 
rhoea, convulsions, coma, and an excessively rapid, weak heart, are 
the chief symptoms, (c) Hemorrhagic scarlatina. This is character- 
ized by severe fever and brain symptoms at the onset; incomplete 
exanthem, necrosing angina, marked glandular and splenic swelling; 
subcutaneous, serous, and mucous hemorrhages with exulceration. It 
is usually lethal after ten to twenty hours from hyperpyrexia, exhaust- 
ing vomiting, diarrhoea, sopor, delirium, convulsions, and dyspnoea. 
It is encountered especially in reduced subjects under two years of age. 

2. Very light cases may present (a) all the usual signs, though 
but mildly developed; or (b) some symptoms may be absent (scar- 
latina fragmentaria) , as in cases with no temperature (scarlatina sine 
febre), no rash (scarlatina sine exanthemate) , or no angina (scarlatina 
sine enanihemate) . In some atypical cases a definite diagnosis is 
impossible, as in acute nephritis with uraemia, fever, sore throat, and 
gastro-enteritis, without the characteristic rash. Recurrent forms are 
not frequent. They occur in the middle of the third week, and result 
from incomplete elimination of the virus during the first attack. Many 
of these cases are septic complications rather than actual recurrences. 
According to Koerner, only forty relapses are on record. 

The differentiation is as follows: 

Scarlet Fever. vs. — — — Sepsis. 

Bright-red erythema, with small red A very deep purple-red rash, sometimes 

papules. spreading over entire body. 

The eruption is much the same in both diseases, the same places being exempt. 
Miliaria are rare. Frequent. 

Rather typical desquamation. Desquamation also observed, but less 

frequently. 
Criteria (q. v.): angina, tongue, abrupt Etiology (lacking in cryptogenetic type), 

onset, glands, etc. chills, sweats, fever irregularity, clinical 

course, polymorphous exanthems, etc. 



92 THE SPECIFIC INFECTIONS 

Diphtheria is often differentiated with difficulty. A simple ery- 
thema is sometimes, though not very often, observed in diphtheria. 
When present it is darker, is located more on the trunk, and is more 
transitory than in scarlatina (see Throat Complications). 

Drug rashes, from belladonna, quinine, iodide, chloral, or copaiba, 
may be easily differentiated, if the cardinal signs rather than the rash 
alone are considered. 

Measles and German measles (q. v.). Acute exfoliating dermatitis 
also begins with fever, with a spreading erythema, and very early 
desquamation, but the other cardinal criteria of scarlatina are lacking. 
Erythema is more transitory; the points are absent; it occurs with less 
fever and without angina or adenitis. 

Erysipelas presents a sharp border, cedematous swelling, marked 
pain, and a slow advance. 

Prognosis. — This should always be guarded for at least one month. 
The outcome often depends on the genius epidemicus, since the mor- 
tality ranges between 2 and 40 per cent. The death-rate averages 
about 10 per cent. The prognosis is least favorable in hospital cases 
and in children. Most deaths occur under six years; in children 
under five years, the mortality is 20 to 30 per cent. (Holt), In the 
first year of life the disease is very fatal. 

The social status, severity of the infection (hemorrhagic forms, severe 
nervous toxaemia), complicating sepsis, necrosis in the throat, otitis, 
nephritis (ursemia, hydrops), heart complications 'high pulse-rate 
being always unfavorable), respiratory complications, and laryngeal 
obstruction, are factors in the prognosis. 

Treatment. — There is no specific therapy and the disease runs its 
self-limited course. 

I. Prophylaxis. — Prophylaxis is equally imperative in both severe 
and light cases. Indeed, the light or ambulatory forms are often the 
more dangerous. Isolation is important, because susceptibility, espe- 
cially in the young, is not universal and the virus is less penetrative 
than in measles, and it is therefore possible to circumscribe its diffusion. 
Care should be taken to prevent transmission through schools and 
by means of fomites and by third persons. The infected room should 
be kept empty for one month, and should be exposed to the wind and 
sun for several weeks. No susceptible person should use the room 
for several months. The physician should wear an operating gown 
and carefully wash his face, beard, and hands, after leaving the sick- 
room. Quarantine should be maintained from six to eight weeks. Even 
this is probably too short a period. A sheet saturated with carbolic 
acid or formaldehyde, and hung before the door, is of no special value. 
Formaldehyde fumigation has been discussed under smallpox. Care in 
surgical and puerperal cases is important, but fhe danger has been over- 
estimated. All discharges should be disinfected. Bichloride wrappings 
should be placed about the dead body, and the funeral should be private. 

Schools should be closed during epidemics. In hospitals the cases 
of scarlatina with streptococcus infection should be separated from 



SCARLET FEVER 93 

cases of simple scarlatina . Sound children should be sent away from 
the house and isolated lest they spread the disease. If they remain at 
home, about one-quarter of them will contract scarlatina (Chapin). 
II. General Treatment. 1. Position. — The prone position in bed 
is imperative in all cases, both during the disease and in the first two 
weeks of apyrexia. 

2. Room. — The room should be light and well ventilated, though 
somewhat warm, especially in convalescence. A grate fire is advisable, 
and the windows should be open at the top. The air should be kept 
dry, since dampness tends to promote nephritis. During the fever 
the skin should be covered with linen, and in convalescence with wool. 

3. Skin. — The eruption should be brought out, when necessary, by 
pilocarpine (Demma) or with mustard baths. During the fever, the 
patient should be washed daily with warm water and soap, though 
unnecessary exposure should be avoided. The tension of the skin is 
thus lessened, the fever decreased, and toxsemic symptoms, such as 
insomnia and restlessness, are allayed. During desquamation, oil- 
rubs may be employed to decrease the risk of infection by dissemina- 
tion of dry scales. They are, however, now considered deleterious, 
as they decrease "the functions of the skin, which are of great im- 
portance when the kidneys are involved. Besides, infection is more 
probably carried by means of throat secretions, than by desquamation. 
Soap and warm water serve equally well. The author is opposed to 
antiseptic soaps because of the chance of absorption which may re- 
sult in renal injury. 

4. Fever. — The following is a harmless fever mixture: 

Liquoris ammonii acetatis §iss. 

Tincturse aconiti Tt^xxiv. 

Syrupi limonis g'ss. 

Aquae q. s. ad gvj. 

Misce, fiat mistura. 

S. — One to three teaspoonfuls every four or five hours, according to age. 

This mixture tranquilizes, promotes the rash, and allays fever. Hydro- 
therapy is useful, such as the warm sponge or full warm bath. Special 
care is indicated (a) in adynamic cases, because of danger of heart- 
failure; therefore the full cold bath should always be avoided and 
the moderately warm bath should be used; (6) in pericarditis; (c) 
in stenosis of the air-passages, or dyspnoea; (d) in hemorrhagic forms; 
(e) in arthritis; and (/) in nephritis. 

5. Diet. — Water should be given very freely. A fluid diet is indi- 
cated by the fever, the percentage of renal complications, and the dys- 
phagia. This may consist of concentrated foods, milk, soups, and 
jellies. In defervescence, milk-toast, custard, puddings, and bread 
andbutter, may be given. Eggs may cause albuminuria, and should 
therefore be avoided. After defervescence, meat, chicken, and fish, 
may be allowed. Meat is given by some clinicians because the urea 
is usually eliminated easily. Fruit and vegetables may be given freely 



94 THE SPECIFIC INFECTIONS 

at all stages, if this can be done without injuring the throat. In severe 
throat complications, rectal feeding is indicated. (See Gastric Ulcer.) 

6. Scarlet Rheumatism. — The A.B.C. liniment (aconite, bella- 
donna, and chloroform), warm wool and flannel bandages, are helpful. 

Tr. opii 5iij. 

Acidi carbolici 3j. 

Tr. belladonnae 3iij. 

01. camphorati 3iv. 

M. et S. — May be applied on muslin covered by cotton 

Salicylates are beneficial in some cases, but unless given in careful 
doses may injure the kidneys. If the arthritis is obstinate, aspiration 
with all surgical care and even drainage may be indicated. 

7. Angina. — Ice in the mouth, ice-cravats, hot fomentations espe- 
cially for the enlarged glands, and DobelFs solution as a nasal douche 
should be given. Care should be exercised in the use of antiseptics 
lest children swallow them. A 10-per-cent. peroxide of hydrogen, 2- 
per-cent. chlorate of potash, or 2-per-cent. carbolic gargle, may be used. 
Formalin gargles are too irritating. Caustics are useless. 

For the nose the following formula is excellent : 

Acidi carbolici 3ss. 

Acidi borici 3ss. 

Glycerini : . . 5j. 

Tr. myrrhse §j. 

Aquse q.s. ad §v. 

M. et S.— Locally, in such dilution that no irritation is felt. 

Huebner injects 3-per-cent. carbolic solution into the tonsils (5ss 
b.i.d. on each side). A 10-per-cent. nitrate-of-silver solution is used 
with great advantage in the early stages of the angina. Coincident 
diphtheria is treated by means of local measures and antitoxin (de- 
scribed under diphtheria), and the antistreptococcus serum may be 
tried in streptococcic angina. 

8. Lymph Glands. — Secondary infection may occur, against which 
prophylactic care of the mouth and throat is important. Ice should 
be applied in the beginning only, and later hot boric-acid dressings 
when the blood- and lymph-streams become stagnant. Iodine and 
ichthyol salves and surgical intervention are indicated in the order 
named. 

9. Otitis. — Otitis is treated by copious boric irrigation, given quite 
hot and at a slight elevation, and followed by equal parts of glycerine 
and laudanum, 5-per-cent. carbolic acid, or 5-per-cent. cocaine in olive 
oil. Leeches over the mastoid often relieve the pain. Examination 
of the drum is rather impracticable in children with small sensitive 
meatus. There is said to be no harm in awaiting spontaneous rup- 
ture, but early puncture under cocaine is much safer. After rupture, 
cotton with a small amount of iodoform or boric powder should be 
applied. 



SCARLET FEVER 95 

10. Nephritis. — Nephritis is treated (a) according to the old prophy- 
lactic rule, by which all cases, severe or light, are confined to bed for 
at least four weeks. The urine must be watched. An albuminous 
diet is said not to be contraindicated, since the urea is usually well 
eliminated, but, according to Jaccoud, the milk diet is valuable in the 
prevention of nephritis. Irritants, like cantharides, are always to be 
avoided. Tepid baths lasting a quarter of an hour should be given 
daily, especially in convalescence. Watch the temperature and the 
urine in convalescence. Wiodowitz in 102 cases used urotropin 
successfully as a prophylactic. The number of his cases is too small 
for generalization, but his results are at least suggestive, (b) Treat- 
ment of established nephritis. Hot baths increase the sweat and the 
flow of urine. They should be given twice daily, and may last for even 
an hour, but the patient must be kept afterward between blankets. 
Alkaline diuretics, such as potas. acet., pot. bicarb., p. citrat., and 
infus. tritici repentis, may be given; pilocarpine for a child two years 
old, 4*0 to 2*5 gr., will often relax the skin. (See Treatment of Ne- 
phritis.) Calomel must be used with great care as a laxative and 
diuretic. Digitalis in moderate doses aids diuresis. 

Infusi digitalis 3 v. 

Potassii acetatis 5ss. 

Syrupi simplicis •. 3 ij • 

Aquse q.s. ad §ij. 

M. et S. — One teaspoonful every two hours. 

High arterial tension should be treated with nitroglycerine. For 
convulsions, chloroform, chloral, and bromides are valuable. For 
vomiting, iodine is most efficacious (see Vomiting Typhoid). Vene- 
section and the administration of digitalis are necessary in severe 
pulmonary oedema. For marked uraemia, two drops of croton oil in 
milk or placed undiluted on the tongue, should produce free catharsis 
in two hours. If not successful by that time it should be repeated. 
Powdered jalap (gr. xv. to 5j-) will unload the bowels in less urgent 
cases. Early evacuation is indicated in pleurisy, if chain cocci are 
found by puncture. 

11. Tonics. — Such tonics as iron, arsenic, and cod-liver oil, are indi- 
cated in convalescence. The heart must be watched for weeks, be- 
cause the heart is very often degenerated. 

12. Serum. — Marmoreck's and other streptococcic sera have given 
no definite general results, although in four instances the author has 
seen good results. Everything depends on whether the streptococci 
are the primary cause or only secondary symbiotic organisms. Again, 
immunization against one variety of streptococcus does not produce 
immunity against other varieties. In Vienna, Moser's serum has ap- 
parently been efficacious. In the St. Anna Children's Hospital, the 
mortality was 8 per cent., and in other institutions it amounted to 14.5 
per cent, without serotherapy. 



96 THE SPECIFIC INFECTIONS 



MEASLES (MORBILLI, RUBEOLA). 

Definition. — An acute, highly infectious disease, characterized by 
an initial coryza and other inflammations of the air-passages, by a 
rapidly spreading eruption, a fever-curve with a double summit, and 
by toxaemia. 

History. — Its first clear description dates from Rhazes (980-1037 
A.D.). It is a very old disease and was widely epidemic in the eigh- 
teenth century. 

Etiology. — (a) Susceptibility is almost universal; few individuals 
escape (14 percent, only [Madsen]), and one attack generally confers 
immunity, though this is sometimes congenital. A second attack is 
relatively rare, although third and fourth attacks are known to have 
occurred, (b) Age — It is rare during the first five months of life, 
and it occurs most frequently after the first year. Twenty instances 
of placental transmission to the child are reported. It is more common 
in adults than is scarlet fever. In Schwalbe's collection of 16,981 
cases, 50.4 per cent, occurred in the first five years; 42 per cent, between 
five and ten years; 5.2 per cent, between ten and twenty years, and 2.4 
per cent, after twenty years of age. (c) Season — Measles occurs 
mostly in the winter and in the cooler spring months, (d) The actual 
virus is unknown. Protozoa are said to have been found bv Doehle, 
and bacilli by Canon and Piclicke. The longevity of the virus without 
the body is not great. It exists in the blood, tears, skin, and in the 
bronchial and nasal secretions. Its activity is greatest during the catar- 
rhal stage, but it is also dangerous during the eruption, and possibly 
even during incubation and desquamation. Hektoen twice succeeded 
in inoculating the disease from the blood of measles patients. 

Propagation usually occurs by personal contact, and rarely through 
a third person. Aerial transmission is frequent, whence isolation in 
the home is not always prophylactic. For this reason the disease 
usually runs through the family. The most frequent means of dis- 
semination is the school-room. It is more often epidemic than is 
scarlatina, and epidemics range more widely through the country. 
They last from four to six months. 

General Clinical Course. — The stages are: (I) Incubation of nine 
or ten days; (II) initial, catarrhal, or prodromal stage of three or 
four days, with fever, catarrhal symptoms in the eyes, nose, etc., and 
an enanthem; (III) the eruptive stage, lasting four or five days, 
with renewed fever, intoxication, eruption, and inflamed mucosae; 
(IV) the desquamative period of variable duration. 

I. Incubation. — The incubation lasts nine or ten (or fourteen) 
days. 

II. Then the catarrhal (initial, prodromal, invasion) symptoms 
appear. These are chilly sensations, malaise, frontal headache, red- 
ness of the eyes, lachrymation, photophobia, coryza, and sneezing; dry- 
ness, redness, and pain in the nose, in the throat, and in the bronchi, 



PLATE II. 



FIG. I. 



FIG. 2. 





FIG. 3. 



FIG. 4. 





The Pathognomonic Sign of Measles (Koplik's Spots 



Fig. 1. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated 
rose-red spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

Fig. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches 
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthem on the skin 
is at this time generally fully developed. 

Fig. 4. — Aphthous stomatitis apt to be mistaken for measles spots.. Mucous membrane normal in hue. 
Minute yellow points are surrounded by a red area. Always discrete. 



MEASLES 97 

and cough, which develops after one day. Vomiting may occur. The 
respiratory symptoms are due to a mucous-membrane enanthem 
(Rehn) which is said to be seen at autopsy on other mucosae. Exam- 
ination of the throat reveals Koplik's spots (Plate II) in 86 to 97 per 
cent, of cases, described by him in 1886, and by Filatow in 1885. They 
are practically constant on the buccal mucosa near the molars, and are 
found on the first day. They are round, of a bluish- white color, and are 
surrounded by a reddish areola. Early catarrhal symptoms are more 
common in measles than in any other acute infection of childhood. 
The initial fever reaches 102° or 103°, and declines gradually during 
the third and fourth days. Occasionally there is a prodromal rash, 
which is mostly hypersemic, though rarely macular or papular. 

III. The eruption begins on the fourth day with papules on the 
temples, cheeks, forehead, and then on the back, wrists, forearms, 
and on the anterior surface of the body and legs, in order of progres- 
sion as named; with the appearance of the eruption, the fever again 
rises. The eruption disappears on pressure or on lateral stretching 
of the skin, and is palpable and superficial. There are always islets 
of normal skin, even in the thickest eruption. The glands are usually 
enlarged and there is more or less marked sweating. 

The general and local symptoms usually abate on the sixth day, 
and the fever falls by crisis. In severe cases, epistaxis, diarrhoea, 
cerebral intoxication, bronchiolitis, pneumonia, hypostasis, cyanosis, 
and asphyxia, may be observed, and death may result from lung in- 
volvement, mixed infection, or decreased physiological resistance. 

IV. Desquamation. — In the desquamative stage the skin pales, be- 
come slightly pigmented, and scales form. Convalescence is established 
in eight or ten days. 

Individual Symptoms in Detail. — I. The Eruption. — It is essen- 
tially the same on the skin and on the mucosae. In the mouth the 
mucosa is red on the first day of fever, andKoplik's spots are found; 
on the second day redness without swelling is especially noted on the 
tonsils and palate. The mucous eruption may reach the larynx, in- 
testines, and genitalia. Though the enanthem tends to spread, the 
skin eruption (exanthem) is circumscribed. The rash is due to hyper- 
emia rather than to actual exudation. It fades on pressure; in some 
cases the roseolas do not fade on pressure, but leave a brown-colored 
area, especially in the nodular forms of measles. The roseola? usually 
are discrete, are slightly elevated, especially in the centre, from spastic 
contraction of the bloodvessels and oedema, are light to dark red in 
color, are round or crescentic in shape, and average 2 to 6 millimeters 
in diameter. They always leave islets of normal skin between the 
independent spots of eruption, even in the most diffuse types. The 
eruption follows a descending order and reaches the lower parts of 
the body last. When the eruption develops on the body first, the 
course is usually anomalous. Itching may be noted, and sweating 
may be marked. Desquamation follows the same order as the erup- 
tion, and is usually fine. Scars never result. The eruption is rudi- 

7 



98 



THE SPECIFIC INFECTIONS 



mentary in those who are debilitated by chronic diseases, and is 
exuberant in the healthy. 

The varieties are: (1) Morbilli Iceves: the usual form, with small 
elevations. (2) M. vesiculosi seu miliares. (3) M. papulosi, nodular 
measles: the eruption may feel slightly "shotty," but such induration 
is always superficial. (4) M. confluentes seu conferti. (5) M. hem- 
orrhagica, benign or malignant (black measles; typhoid, septic, 
adynamic types). (6) M. sine exanthemate ; sine enanthemate. 
" Recession" of the eruption (fading or "striking in") is usually a sign 
of heart-failure. 

II. The Fever. — The curve is not absolutely typical. It begins 
suddenly without a chill, and falls on the second day, perhaps even to 
normal, rises again with the eruption, and reaches its maximum in 
thirty-six hours, thus giving a curve with a double summit. It usually 
falls by crisis before the eruption disappears. Fever, after the eruption 
begins to fade, indicates complications. In rare cases fever is absent. 
The temperature is normal, even subnormal during desquamation. 









Fig 


. 9. 








ll)ay 

TEMP. 


2 


3 


4 


5 


6 




104 














103 A 














102 / \ 














loyv V 














100 














99 










































INITIAL 
RISE 


FALL 




RISE WITH 
RASH 


EXTENSION 
OF RASH 





Fever curve in measles. 

III. The Respiratory Tract. — Nasal catarrh is of special moment 
in sucklings. Epistaxis, fibrinous rhinitis, and diphtheria, are uncom- 
mon complications. Catarrhal laryngitis may occur, accompanied by 
hoarseness and false croup ; 50 per cent, of the cases suffer from ero- 
sions or ulcerations of the larynx (Rilliet and Barthez), 16 per cent, 
from pseudomembranous laryngitis, and 15 per cent, from simple in- 
flammation. Laryngeal complications are not necessarily febrile. 
Bronchial catarrh cannot be excluded by the absence of rales. It 
may reach the smaller tubules and usually, but not always, occurs late 
in the disease. It produces a clear, stringy, viscid sputum which 
may later become purulent and nummular. The bronchial glands 



MEASLES 99 

are always swollen. Simple atelectasis may occur, and may occasion 
indeterminate breathing and dulness, which decreases with change 
of posture or deep breathing. Bronchopneumonia occurs in 6 to 12 
per cent, of the cases and is the most frequent fatal complication. It 
differs from other lobular pneumonias in its rapid development, and 
its greater tendency to pus formation, which result from the fact that 
the measles-catarrh promotes the action of the pneumococcus and 
pyogenic cocci. The temperature is often no higher than in bronchitis. 
There are often bronchial breathing and other physical signs. In 
some cases they may not be detected clinically. Toxaemia and car- 
bon-dioxide narcosis accentuate the patient's distress. Broncho- 
pneumonia is rapid in development, but slow or sometimes incomplete 
in resolution. It may result in interstitial pneumonia, gangrene, or 
tuberculosis. The latter is a dreaded sequel of measles. It occurs 

(a) as a miliary invasion, and develops in the brain much more fre- 
quently than in the lungs. It is caused by the bacilli from old ca- 
seated bronchial glands which are released by solvent substances which 
reach them from the lungs by way of the lymph-vessels. It also occurs 

(b) as a fresh tuberculosis developing upon a bronchopneumonia. 
This variety may heal or apparently recover, to break out anew at 
a later time. Croupous pneumonia is as infrequent as pleurisy. Pleu- 
risy is in most cases secondary to lobular pneumonic foci and may 
cause effusion. 

IV. Cardiac Symptoms. — These are rare. Accidental bruits may be 
heard. Toxaemia may, in exceptional cases, cause myocardial degen- 
eration. 

V. The Digestive Tract. — The tongue is coated. There is thirst 
and aphthae, and stomatitis may be observed. As a result of an intes- 
tinal enanthem, diarrhoea (which is important prognostically) , mucus 
in the stools, and (anatomically) swelling of Peyer's patches, have been 
described. The liver is seldom swollen. 

VI. The Nervous System. — Nervous symtoms, such as delirium, 
sopor, coma, or convulsions, may, in rare cases, result from severe tox- 
aemia, even though the delicate nervous system of children is seldom 
involved in measles. Nervous symptoms may occur in protracted 
pneumonia, and doubt may exist as to whether they are caused by 
the measles, miliary tuberculosis, tuberculous meningitis, or carbon- 
dioxide narcosis. Paralyses, myelitis, muscular atrophy, polyneuritis, 
and polymyositis, are most infrequent. 

VII. Genito-Urinary Tract. — Acetonuria and albuminuria are fre- 
quent. Ehrlich's diazo reaction occurs in nearly 100 percent, of the 
cases. Nephritis is very uncommon. It may occur during desquama- 
tion, but is more often due to complicating diphtheria, or tubercu- 
losis. Gangrene of the genitalia has been observed. 

VIII. Other Symptoms. — The spleen and lymph-nodes are but 
slightly swollen; bone and joint complications are rare; keratitis is 
infrequent; otitis media occurs in a small percentage of cases, although 
some observers have found it in as high as 50 to 60 per cent. It is 

LOFC, 



100 



THE SPECIFIC IXFECTIOXS 



said that streptococci in the conjunctivae are much more frequent in 
severe than in mild cases. The red cells are little altered, while the 
leukocytes show a relative lymphocytosis, with anabsolute leukopenia. 

Differentiation from German Measles and Scarlatina. 



German Measles 



Scarlatina 



Measles 



Incubation: 14 to 21 days. 2 (1 to 7) days. 

Prodromes : absent, short. Brief, a few hours to 1 or 
or light. 1^ days. 



9 to 10 days. 

3 to 4 days, generally 
markedly catarrhal. 



Invasion: very mild. 



Sudden, stormy, vomiting. Catarrhal symptoms, 
convulsions, angina, and 
adenitis. 



Exanthem: the rash is the 
first symptom, usually 
appearing on the first or 
second day od the face; as 
small red dots, rosy and 
brighter than in measles: 
small, little elevated, and 
thick about the mouth. 
They do not fuse. Less 
crescentic than in mea- 
sles. 



Appears on first or second Occurs on fourth day, 
day, reaching a maximum greatest on fifth or sixth 



on second to fourth day. 
first below clavicles, in- 
volving face later, dusky- 
red, diffuse, burning, leav- 
ing mouth and eyes free 



day, on the face, forehead, 
and about the mouth; 
brick-red elevated pap- 
pules or crescentic islets 
of eruption, always with 
areas of healthy skin be- 
tween. 



Enanthem, etc.: may be Angina proportionate to Koplik's spots; patchy red- 



diffuse redness of throat 
and conjunctivae. 



skin eruptions; dusky 
red; tonsillar plugs; con- 
junctiva?, bronchi, intes- 
tines usuallv intact. 



ness of throat; photo- 
phobia; conjunctivitis, 
marked bronchitis, very 
often bronchopneumon- 
ia; - diarrhoea in some 
cases. 



Glands: usually enlarged. Proportionate to angina, Mostly at angle of jaw; 
hard, tender, especially hence largely cervical, rarely systematic en- 
posterior cervical, also Enlarged spleen. largement. Xo enlarge- 
axillary and inguinal. ment of spleen. 
Spleen somewhat en- 
larged. 



leukocytosis; little pulse 
increase and fever. 



with two elevations; cri- 
sis on seventh day; no 

leukocytosis. 



Constitutional symptoms: Much depression with rash, Depression, coated tongue, 
few; no depression; no coated tongue with peel- anorexia; fever-curve 
ing on . the fourth day 
(Strawberry tongue); fe- 
ver 105° to 106°; pulse 
increased more than fe- 
ver; lysis on seventh day : 
leukocytosis. 

Complications: practically Nephritis, arthritis, endo- Catarrhal pneumonia, pleu- 
none. carditis, sepsis, periaden- risy, tuberculosis, 

itis. 



Convalescence: rapid; des- Prolonged, tardy; desqua- Often prolonged; desqua- 
quamation rarely copious, mation copious and usu- mation rarely copious 
and always fine. allv in shreds (hands and and always fine, 

feet). 



MEASLES 101 

Diagnosis. — The diagnosis depends upon the existence of an epi- 
demic, and upon consideration of all the symptoms rather than of 
the eruption alone. Differentiation from typhus, where there is also 
catarrh, is made by the greater general disturbance in typhus, its 
more sudden onset, higher fever, greater swelling of the spleen, and 
by the fact that the roseolous eruption becomes petechial and is least 
marked on the face. 

Sepsis with a morbilliform exanthem, the early stage of influenza, 
syphilis (in which other secondary symptoms appear with the erup- 
tion), and variola (q. v.), may sometimes delay the early diagnosis. 
In drug-eruptions (those of turpentine, iodides, copaiba, and anti- 
pyrin), the diagnosis may be most difficult. The fever, Koplik's spots, 
catarrh, and central elevations in the eruption, are indications of measles. 

Prognosis. — The mortality is very great among aboriginal races. 
In the Fiji Islands the death-rate was very high. In the Samoan 
Islands 4,000 deaths followed the introduction of measles, in 1893. 
The usual important factors are : (a) The genius epidemicus: Henoch 
records 30 per cent, and Heubner 37 per cent, in some epidemics. The 
mortality in a German epidemic of 2,881 cases was only 1 per cent. 
(Heissler). (b) Individual resistance: in private practice 3 per cent, 
is the average death-rate. It is higher in institutional practice and in 
the army. It is 16 per cent, in the children's hospitals in Paris. 
Measles ranks third among the exanthemata in mortality, (c) Age: 
The death-rate is highest at the second year; 55 percent, of fatal cases 
occur in the first two years of life (Henoch), (d) Complications are 
more important than the disease itself; e.g., tuberculosis and broncho- 
pneumonia, which is the worst complication, with a mortality of 33 
per cent. 

Treatment. — 1. Prophylaxis. — Prevention is important, especially 
in children under two years, in severe epidemics with pneumonia, 
in the weakly, and in cases of pertussis. Though the mortality and 
complications are greater in adults, it is of no advantage to contract 
measles, and the too prevalent practice of allowing the disease to run 
through the family must be condemned. In all cases, the secretions 
from the nose, throat, and bronchi, must be disinfected, and general 
sanitary care should be exercised as in smallpox and scarlatina. 

2. Hygiene. — The patient should have fresh air, a warm room, 
rest in bed until after desquamation, and a liquid diet. A mustard 
bath may be employed in order to bring out the rash. 

3. Catarrhal Symptoms. — Photophobia does not necessitate a dark 
room. Some sunlight should be admitted. A boric-acid solution 
should be dropped frequently into the eyes and vaseline applied to the 
lids. Prophylactic care of the mouth is necessary. To relieve pain 
in the ears, belladonna, opium, and a 1-per-cent. cocaine solution 
may be used; paracentesis is indicated for gathering. The nose should 
be douched with Dobell's solution. Tr. belladonna?, mi i.-iii. may 
be given every two hours for coryza until flushing of the face, increase 
of pulse-rate, or a dry, red throat, develops. 



102 THE SPECIFIC INFECTIONS 

4. Antipyresis. — Antipyretics are indicated (a) in sudden high 
elevation with severe cerebral toxaemia; and (6) in high fever with 
diffuse bronchitis or pneumonia. They are given most efficaciously 
in the form of baths, with cold affusions to the head and neck. Wine, 
leeches to the mastoids, mustard plasters, and laxatives, may also 
be indicated in toxsemia. 

5. The Circulation. — The heart rarely requires treatment, except 
in septic types or in pulmonary complications, when camphor, am- 
monia (aromatic spirits), strychnia, wine, or coffee, are indicated. 

6. Respiratory Symptoms. — Care of the mouth, a soft or liquid 
diet, inhalations of steam, hot fomentations over the larynx, warm 
baths, emetics (such as apomorphine or ipecac), and possibly intubation 
or tracheotomy, are indicated for laryngeal complications. Bronchitis 
should be treated with ipecac, codeine (morphine), emetics, inhala- 
tions of steam, massive hot packs to the chest, and cold affusions over 
the nape of the neck (see Acute Bronchitis); stimulation for pneu- 
monia (q.v.) may be indicated. 

7. Alimentary Tract. — Enemata relieve constipation. When diar- 
rhoea is excessive, opium, hot wine, or cognac, demulcents, hot appli- 
cations, and physiological salt-solution by rectum, are indicated. 

8. The Skin. — The skin should be rubbed with olive oil; a 2-per- 
cent, menthol salve, or 1-per-cent. carbolic solution, relieves itching. 

9. Complications. — The treatment of complications, such as tuber- 
culosis, pertussis, etc., will be described under these topics. 



RUBELLA. 

Synonyms. — Rubeola noiha, German measles, Rotheln. 

History. — Rubella was first described by Bergen (1752) in Ger- 
many, and its separate existence was established by Maton (1815) in 
England, though it is still called by some writers a hybrid form of 
measles and scarlatina. It is more often confused with atypical scar- 
latina than with atypical measles. By the Germans it is called rubeola, 
though we employ rubeola as synonymous with measles. 

Definition. — An independent infection, which occurs often in those 
who have had measles and scarlatina. One attack confers immunity. 

Etiology. — Its etiology is not known. Most cases occur during the 
first half of the year. The disease most frequently attacks children. 

Symptoms. — I. The Incubation. — The incubation lasts from ten 
to twelve (or perhaps fourteen to twenty-one) days. 

II. Prodromes. — Prodromes may be lacking, or for a period of 
from two hours to a day, there may be cough, slight photophobia, or 
sneezing. Slight temperature and a few general symptoms, such as 
chilliness or headache, usually develop. 

III. The Eruption. — The eruption occurs on the first day, usually 
in the palate and throat. It resembles measles, and consists of hyper- 
aemic punctate red spots (Forscheimer's spots). The skin is red, and 



RUBELLA 103 

the eruption disappears at first under pressure; then the macules be- 
come darker and more circumscribed; later, the eruption does not 
entirely disappear under pressure. There are two forms, the cir- 
cumscribed and the diffuse. The eruption becomes slightly elevated, 
does not fuse as it does in measles, and erythema is not present about 
the points of eruption as it is in scarlatina. Anatomically, it is a capil- 
lary hyperemia of the papillary and upper layers of the corium, 
accompanied by slight inflammation and exudation between the corium 
and epidermis. It advances in "jumps," and fades in one place while 
it blossoms in another. It appears first on the scalp and face, and 
progresses downward to the neck, body, arms, and lastly to the 
legs and feet. Unlike scarlatina, spots may be observed about the 
lips. The eruption is greatest on the upper parts of the body, and is 
increased by constriction or by pressure of the clothing. Its average 
duration is from two to four days. The papillae of the tongue show 
slightly through the fur. Desquamation is minimal and fine. Trach- 
eitis, or, rarely, bronchitis, may be observed. Almost characteristic 
is the swelling of the posterior cervical and post-auricular glands. 
There may be some angina, dysphagia, or anorexia. 

IV. The Constitutional Symptoms. — The constitutional symptoms 
are few. The fever is usually slight. Its duration averages three days, 
and it falls by crisis or lysis when the eruption has matured. Except 
in a few American epidemics, urgent nervous and other complica- 
tions, such as icterus, albuminuria, nephritis, or colitis, have rarely 
been observed. 

Diagnosis. — The diagnosis is often very difficult and the unity of 
the disease is sometimes questioned (see Measles). The "fourth 
disease," described by Dukes, is said to present a longer incubation 
and more diffuse rash. Erythema infectiosum, emphasized particu- 
larly by Escherich, is a weakly, contagious, maculo-papular erythema, 
prevalent particularly in the spring and fall, and occurring chiefly 
on the extensor surface of the extremities, and rarely on the trunk. 

Prognosis. — The prognosis is good, and therapy is symptomatic. 
Isolation is theoretically advisable. 



ERYSIPELAS. 

Synonym.— ££. Anthony's Fire. 

Definition. — An acute, febrile, contagious disease caused by Fehleis- 
sen's Streptococcus erysipelatos. It is characterized by a peculiar 
circumscribed inflammation of the skin and adjacent mucosae, which 
tends to rapid and broad extension. It usually runs a self-limited 
course, with slight, if any, visceral involvement. 

History. — Erysipelas was known to Hippocrates and Galen. Trous- 
seau (1848), in France, maintained that it was always a wound 
infection. Werner, in England, maintained that it was an infec- 
tious disease, and Koch (1880) found the streptococcus, which was 



104 THE SPECIFIC IXFECTIOXS 

more fully described by Fehleissen (1881) and which bears his 
name. 

Etiology. — It is wide-spread, and sporadic cases are seen in almost 
every centre of population. It occasionally breaks out epidemically. 
It prevails largely in the early spring months; 60 per cent, of cases 
occur between January and May (Anders). In the preantiseptic 
era it was the dread of hospital physicians, and even at this day it 
occasionally visits the most sanitary institutions. It is conveyed by 
a third person and by fomites; and, infrequently, by unclean instru- 
ments, and vaccine. Cases of placental transmission to the foetus are 
known. The virus is not particularly penetrating but may adhere to 
clothing and furniture with great tenacity. Individual predisposition 
varies, but many persons have, apparently, a natural, or perhaps a 
hereditary, susceptibility to the disease. It is like rheumatism or acute 
angina, in that it often recurs repeatedly. It occurs mostly in the female 
sex (73 per cent, of the cases). Alcoholism, debility, and chronic ne- 
phritis, are predisposing factors. Any distinction between "idiopathic" 
and "wound'' erysipelas is artificial, for in practically every instance, 
some abrasion, though perhaps too small for the eye to detect, occurs 
in the skin or mucosa?. 

Bacteriology. — The Streptococcus erysipelatos (seu pyogenes longus) 
was found in the lymph-vessels by Fehleissen, who first drew the dis- 
tinction between erysipelas and phlegmon. Though it strictly coincides 
with Koch's criteria, its absolute differentiation from the Streptococcus 
pyogenes is impracticable. Inoculations from cases of erysipelas 
sometimes produce suppuration. Pus from abscesses has caused 
erysipelas, and, in certain cases, erysipelas and suppuration have de- 
veloped simultaneously. This has given some weight to the theory 
of the bacteriological unity of erysipelas, suppuration, and septi- 
caemia. 

Symptoms. — I. Incubation. — Incubation lasts from three to seven 
days (fifteen to seventy-two hours in direct inoculations). 

II. The Eruptive Stage. — (a) This stage usually begins with vomit- 
ing, fever, chill, and the eruption, and is sometimes preceded by gen- 
eral symptoms, such as fatigue, anorexia, or pains in the joints. The 
fever rises rapidly to 103°. The chill, occurring in 75 per cent, of the 
cases, is usually preceded by a few hours of general discomfort. It 
Is absent chiefly in erysipelas which is secondary to other diseases. 
(6) The eruption, in typical cases, first appears on the face (95 per 
cent, of the cases), near the inner canthus of the eye, near the nose, 
or on the cheek. It consists of a hard, bright-red, slightly elevated, 
burning, and painful area of inflammation, which pits but little" on 
pressure, though its color may disappear. Pathologically, erysipelas 
is simple inflammation; in and under the skin are found oedema, 
hvpera?mia, white- and red-cell extravasation, and streptococci which 
advance in the lymph-clefts, and are most abundant in the spreading 
edo-e, but are also found in the lymph-vessels beyond it. Its elevated 
red edo-e is sharply marked, or "wall-like." As the area spreads, 



ERYSIPELAS 105 

the skin becomes much swollen, cedematous, smooth, tense, red, and hot, 
causing a shapeless swelling of the eyes, nose, lips, and ears, and ob- 
literating the facial lines and expression. The extent of this area is 
indicated by tenderness, and is therefore more accurately measured 
with the finger than with the eye. Under the lens, small vesicles are 
always found. The prong-like advance of the eruption is similar to 
that of spilt alcohol, or, as Volkmann puts it, like burning paper; i. e. 
it disappears behind as it advances forward. Its extension is irregular, 
because the streptococci follow the line of least resistance. If obstructed 
by dense tissue, deep attachments, or the so-called ligamenta cutis, 
its course becomes circuitous, asymmetrical, and tardy in one area 
though rapid in another. It is limited at the base of the skull, and 
rarely affects the chin, or passes over it to the opposite side. The neck 
resists its advance, often successfully, but erysipelas may course over 
the entire body. The sternum, condyles, ilium, and Poupart's liga- 
ment, check or divert its progress. When apparently obstructed, new 
islets of eruption appear near by, which are nearly always consecutive, 
as may be seen by the faint lymphatic involvement between the foci. 
The scalp is often unaffected, but if invaded it becomes swollen, tense, 
and pale or blue rather than red, and the hair falls out. The genitalia 
may swell enormously. Necrosis of these tissues, and also of the 
elbow and knee, may result from excessive tension. The first area 
pales, and a coarse desquamation results, while the eruption at more 
remote points advances. The lymph-glands are almost constantly 
swollen, tender, and are palpable, unless hidden by oedema. They 
bacome enlarged proportionately to the dermatitis. The eruption 
presents few variations : erysipelas miliare (vesiculosum) ; less frequently 
erysipelas bullosum; erysipelas squamosum, or, in old and cachectic 
subjects, erysipelas hemorrhagicum. (c) The jever rises suddenly, and 
is highest on the third or fourth day (103° to 104° or higher). It is 
continuous, then becomes remittent or irregular, and finally, after 
seven to nine days, resolves by crisis, or less often by lysis. Fever is 
almost always present; in very rare cases is it wholly absent. In at- 
tenuated erysipelas there is little fever and there are few general symp- 
toms, though the rash may be well developed. In general the intensity 
and the progress of the infection are marked by the degree of fever. 

Other General Symptoms. — The pulse is soft, and ranges between 
100 and 120; albuminuria occurs in 38 to 67 per cent, of the cases; 
moderate leukocytosis is the rule, and there may be some pain and 
swelling of the liver and spleen. Nervous toxaemia, with the exception 
of headache, is uncommon. 

Course. — When limited to the face and head, eight to ten days 
is the usual duration, and a course longer than two weeks is uncom- 
mon. Erysipelas migrans may last weeks or months, travel from limb 
to limb, and recur again and again. In one of the author's cases it 
lasted six months. 

Complications and Sequels.— 1. Nervous. — Toxsemic symptoms 
are infrequent except in aged, debilitated, or alcoholic subjects. 



106 THE SPECIFIC IXFECTIOXS 

Delirium is toxemic, but was considered reflex, resulting from trigem- 
inous involvement, by Traube and Jaccoud. It is an unfavorable 
development and occurs especially when the scalp is invaded. A pro- 
found typhoid condition may occur in debilitated, or alcoholic cases. 
Meningitis, formerly confused with toxaemia, infrequently follows or- 
bital cellulitis or extension along the fifth nerve. Post-febrile psy- 
choses, multiple neuritis, and degeneration of the cord, are exceptional. 
Eye inflammation, ulceration, and blindness, are very infrequent. 

2. Circulatory. — Endocarditis is infrequent though simple and ul- 
cerative types may develop. Pericarditis, myocarditis, acute dilata- 
tion, and arterial or venous thrombosis, are infrequent. Leukocytosis 
is usually moderate, and is generally parallel with the fever. High 
counts usually indicate concomitant suppuration. Streptococci in the 
blood are usually, but not necessarily, ominous. 

3. Respiratory. — Erysipelas may invade the nose, throat, ear, 
larynx, and bronchi, and begins with local symptoms or with chill 
and fever. Erysipelatous coryza, otitis, and stomatitis, are infrequent 
and are difficult of recognition. Erysipelatous angina is characterized 
by much pain, sharply marked redness or lividity, a glazed varnished 
surface, marked oedema of the uvula and epiglottis, and the forma- 
tion of vesicles or bulla?. Sometimes a wall-like margin is seen. Gan- 
grene may develop in severe instances. The neck glands may be 
swollen. For the recognition of erysipelatous angina, coincident facial 
erysipelas is necessary. 

Laryngeal erysipelas is more often secondary (to pharyngeal erysipe- 
las) than it is primary. It is rare, severe, is easily or necessarily con- 
fused with glottis oedema, and is marked by great turgescence, rapid 
spreading and swelling, and high, early fever. Without trache- 
otomy, fatal stenosis and extension to the lower air-passages may 
occur. The rare so-called "erysipela spneumonia" is especially de- 
scribed by French writers. Though the existence of this type cannot 
be denied, because any infection may travel downward from the throat, 
it is more probably a septic localization than "internal" erysipelas. 
In streptococcus pneumonia, the spleen is enlarged (sepsis) more fre- 
quently than it is in ordinary pneumonia. The advance is rapid, the 
extension is wide, the gray hepatization is great, and fibrin formation 
is scant or lacking. Nevertheless, in pneumococcus infection the same 
"wandering pneumonia" may be seen. Pleurisy is usually metastatic 
(septic). 

4. Alimentary. — Vomiting is often cerebral. Exceptional com- 
plications are parotitis, oesophagitis, gastritis, enteritis, intestinal 
ulceration, hemorrhage, pain, icterus, and pylethrombosis. 

5. Genito-Urinary. — Albuminuria (67 per cent, of the cases) is the 
most constant visceral finding. Nephritis (4 per cent.) is often of the 
acute glomerular type, and rarely becomes chronic. Streptococci have 
been seen in the urine and kidneys, especially in septic types. Typical 
erysipelas may begin in the external genitalia, especially in puerperse, 
or mav first infect the internal mucosa which has been abraded dur- 



ERYSIPELAS 107 

ing labor. There may be great pain, local necrosis, and imminent 
risk of higher or peritoneal invasion. Accurate diagnosis of the inter- 
nal form of erysipelas (E. puerperale grave internum, Virchow) can 
seldom be made. 

6. Septic — Subcutaneous abscesses, which are usually small, and 
which resemble cold abscesses (Tillmann, Alcalme), appear on the 
head or body, occur in 6 per cent, of the cases, especially in alco- 
holic, nephritic, diabetic, or debilitated patients. Phlegmons may de- 
velop, usually on the legs, and are known to occur even without mixed 
infection. Gangrene is fortunately rare ( £ of 1 per cent.) . It may de- 
velop early, in the eye-lids, in the genitalia, over the lean tissue cover- 
ing the joints, or it may develop later in the extremities. Herpes is 
not infrequent. Baldness may also result. The joints may be painful 
or swollen. Suppuration is metastatic. Suppurative adenitis may 
occur with or without mixed infection. General fatal sepsis, aside 
from the puerperal form, is infrequent. It bears the same relation 
to local erysipelas as does miliary tuberculosis to a local tuberculous 
focus (Ponfick). 

Diagnosis. — Diagnosis is easy, when the area is the size of a dollar, 
(a) because of its very location; (b) because of the early involvement 
of the lymphatics and of the lachrymal sac; (c) because in most cases 
the point of entrance can be found; it may have healed; it may be 
concealed by the swelling, or lie an inch or more away from the first 
eruption; (d) because of the redness, smoothness, swelling, and oedema; 
(e) because of the elevated, wall-like margin ; and (/) because of the 
prong-like, irregular progression. 

In weeping eczema, the edges are not raised, the skin is not smooth, 
there is less fever, and the development is slower than in the ordinary 
type, and itching is present. Malignant pustule may cause redness and 
swelling, but anthrax bacilli are found under the primary papule and 
crust. Dermatitis venemata, or medicamentosa, and pemphigus, are 
unlike erysipelas. Erythema nodosum is discrete, though diffuse, and 
does not spread. Diffuse simple erythema is a febrile affection, and of 
short duration. Dermatitis exfoliativa (Ritter) in the new-born is 
afebrile, develops first about the mouth and chin, and reaches the body 
and limbs later. Its diffuseness and redness are characteristic. In 
lymphangitis the swelling of the lymphatics advances toward the centre 
and presents cord-like or net-like areas, which are neither confluent, 
vesiculated, uniformly red, nor evenly edged. In phlegmon and deep 
cellulitis, the process is deeper and harder, and the blisters and margin 
of erysipelas are lacking. 

Erysipelatous angina may not be diagnosed without coincident 
facial erysipelas. The local findings, such as great swelling, dysphagia 
and lymphatic enlargement, are not pathognomonic; neither are the 
general findings, such as high fever, albuminuria, nephritis and splenic 
tumor. 

Erysipeloid, a zoonotic affection described first by Rosenbach, 
occurs especially in persons whose occupation leads them to handle 



108 THE SPECIFIC INFECTIONS 

meat. It is recognized by the "butterfly" eruption which develops 
on both cheeks or on the finger-ends, and is unaccompanied by fever 
or general symptoms. The edge of the eruption is clear-cut, its ad- 
vancement slow, its color a dark livid-red, and its course lasts one to 
three weeks with spontaneous recovery. Gilchrist (1904) reported 
329 cases, of which 323 were caused by crab-bites. 

Prognosis. — (a) In uncomplicated facial erysipelas the outlook 
is good. In general the mortality is 3 to 4 per cent, in private practice, 
and double that figure in hospitals, (b) In erysipelas migrans the 
outlook is less favorable, (c) In erysipelas neonatorum (Trousseau, 
Lorain) the outlook is almost invariably fatal on the fifth to seventh 
day. It begins on the navel, and less often on the vulva, and on cir- 
cumcision-wounds. Vomiting, diarrhoea from toxsemia, peritonitis, 
icterus, pneumonia, necrosis, gangrene, suppuration, and sepsis, are 
much more common than in adult forms. Fortunately, like puer- 
peral fever, this form is now infrequent, (d) Erysipelas secondary to 
other infections is serious, especially in chronic maladies, such as 
alcoholism, diabetes, nephritis, and tuberculosis, and also in bed-ridden, 
or senile subjects, in whom the asthenic, hemorrhagic, or gangrenous, 
types are chiefly observed. In acute diseases such as typhoid, diph- 
theria, and pneumonia, this complication is dreaded, (e) Puerperal 
forms or involvement of the mucosa, especially that of the larynx, are 
unfavorable (Hippocrates). (/) Recurrence is more frequent than 
in any other infection, which shows that no permanent immunity is 
conferred. Relapses (10 to 15 per cent, of the cases) are attacks recur- 
ring within a few days. Recurrences (20 to 50 per cent.), properly 
speaking, return after months or years; indeed, in some individuals, 
erysipelas may be called habitual. It is observed most frequently 
in the young and in women (75 per cent.), and mostly on the face. 
It may result in elephantiasis. Five to fifteen attacks are not uncom- 
mon, and Roger has seen forty in one person. 

Treatment. — 1. Prophylaxis. — In this bacteriological era, the dis- 
ease has been decreased by means of asepsis and isolation, though in 
regard to the latter, many physicians are still remiss. Chronic rhinitis, 
rhagades, decayed teeth, and neglected ulcers, must be considered in 
cases of habitual erysipelas. 

2. Mechanical Means. — Mechanical efforts to limit the extension 
of the disease are still used, but unsuccessfully. These consist of 
binding with elastic strips, elastic constriction, or heavy applications 
of collodion. 

3. Local Applications. — Iodine, creolin, bichloride of mercury, car- 
bolic acid, alcohol, iodoform, boric acid, and numerous other topical 
applications, may be recommended, but the water they contain is the 
best ingredient, and was recommended by Hippocrates himself. 
Mechanical and local applications cannot reach the deeply-situated 
cocci. Cold compresses afford a sure relief for pain and tension. 
Ichthyol ointment, 10 to 20 per cent., is soothing but in no sense 
curative. 



MALARIA 109 

Creolin 1 part. 

Iodoform 4 parts. 

Lanolin 10 parts. 

M. f. ung. (Koch.) 

4. Drugs. — Erysipelas is a self-limited disease, therapeutically un- 
approachable. Tincture of the chloride of iron (Hamilton Bell, 1861) 
is well tolerated in large doses (tt^-x-xxx) but neither shortens nor miti- 
gates the disease. 

Tincturae ferri perchloridi 5iiss. 

Quininae sulphatis gr. xxiv. 

Spiritus chloroformi 3ij. 

Aquse q. s. ad §vj. 

M. f. mist. 

S. — Two tablespoonfuls every three or four hours. (J. Burney Yeo.) 

5. General Treatment. — The symptoms are managed expectantly, — 
i. e., as they arise. Headache, delirium, pain, vomiting, and cardiac 
weakness, are treated as in typhoid. Rest in bed and as generous 
nourishment as the stomach will tolerate, are indicated. 

6. Marmorek's Serum. — Chantemesse reduced the death-rate of his 
cases to 2\ per cent, by serum treatment, a figure often reached by 
more simple measures (Roger and Botognesi). 

Erysipelas as a curative agent (erysipelas salutare): Permanent 
cure of lupus has followed a complicating erysipelas. Syphilis quickly 
subsides after this infection, and its beneficial effects have been ob- 
served in leukaemia, Hodgkin's disease, carcinoma, sarcoma, chronic 
arthritis, rheumatism, iritis, tuberculous adenitis, neuralgia, diph- 
theria, and tuberculosis. 



MALARIA. 

Definition. — An acute infection caused by the Plasmodium malarige, 
inoculated in man by the mosquito and characterized clinically by 
(1) paroxysms of intermittent, quartan, tertian, or quotidian fever, or 
by (2) remittent or subcontinuous fever, and sometimes by (3) perni- 
cious, or (4) chronic cachectic forms. 

History. — Malaria, known to Hippocrates and Celsus, is the dis- 
ease most completely investigated, in that (a) its cause is exactly known; 
(b) its prophylaxis has become known since the discovery of infection 
by the mosquito; (c) the disease can be watched in different stages 
in the blood; and (d) there is a specific treatment. 

Etiology. — All ages and both sexes are affected equally. Men are 
more exposed to infection, and children are readily infected on ac- 
count of their thin skin. Such occupations as sewer and railroad 
building, ditching, and night work, especially, are predisposing factors; 
32 per cent, of the French soldiers in Madagascar in 1895 acquired 
malaria; reduced physical resistance, exposure, excesses, and alcohol- 



110 THE SPECIFIC IXFECTIONS 

ism, also predispose to the disease. Negroes have a relative immunity. 
Instances of familial or individual immunity have been noted. Epi- 
demics may occur, as happened during the building of the Paris 
boulevards. Indirect causes, such as warmth of climate, the warm 
season, moisture, rain, swampy localities, telluric influences, bad air 
(mal-aria), and impure drinking-water, are now proved to be causes 
only in so far as they relate to the breeding of the mosquito. In Africa, 
severe forms of malaria are found everywhere except in the lower part 
and in the Sahara. In the far East its chief seats are India, Burmah, 
Assam, Faral, and the East Asiatic coast; Asia Minor, Japan, and the 
East Indies. In Europe, lower Russia, Italy, Hungary, the Balkans, 
and Greece, are most affected. Malaria also abounds in South America, 
in the northern three-fourths of the continent. In the West Indies, 
severe types prevail. In the United States, malaria is slowly moving 
southward, and cases seldom develop on the Pacific coast, in the 
Northwest, in the dry West and, in the Lake region. Even in the 
South it is becoming less frequent. 

Direct Cause. — The direct cause is the malarial parasite, described 
by Laveran, in 1880, and also by Marchiafava and Celli, in 1885. In 
this country Councilman, Abbott, Osier, James, Dock, Koplik, 
Thayer, Hewetson, and others, have studied the disease. It is a red- 
cell parasite, a hsemocytozoon. The biology of the Plasmodium ma- 
larise concerns (A) its life in the human blood, and (B) its life in the 
mosquito. The unity of all species was maintained by Laveran, but 
various species must be recognized because (1) their morphology 
varies; (2) their geography, seasonal prevalence, and malignancy 
also vary; (3) on inoculation, the species and fever type are main- 
tained; (4) the type remains the same in the same individual. 
(A). The Plasmodium in Man. — Special forms of the parasite: 
1. The quartan parasite has a life-cycle of three days. In the first 
twelve hours the young form is without pigment. A small amor- 
phous hyaline bright spot lies in the red cell, whose form flattens the 
parasite. There is some amoeboid movement upon w T arming the slide. 
It gains little in size for one day, when some pigment or melanin ap- 
pears in the form of coarse dark rods and granules with little move- 
ment. Melanin is the haemoglobin digested by the parasite. It is 
usually dark or black and resembles the melanin of malignant growths. 
It is dissolved by alkalies and ammonium sulphide, but not by acids. 
Movement of the parasite ceases as pigment increases. The para- 
site occupies one-half to two-thirds of the red cell after forty-eight 
hours, and almost the entire cell after sixty hours. There is rarely 
more than one parasite in each cell. Flagella (v.i.) are not frequent. 
During growth the red cell on which the plasmodium feeds either 
undergoes no change in size or becomes smaller and darker periph- 
erally. As sporulation occurs, the pigment gathers centrally and 
the spores, usually not numbering more than ten, develop into the 
" daisy" form. Vacuoles are seen in some cases. After sixty-nine 
hours, mature segments finally separate, each with a bright spot or 



PLATE III 



a 








^ 




■■■■«/ 



10 



:j 



3 



>v |) %| 



s ^ 



;: ; :-:. 
^ 



10 



B 



■& 





: 






7 






„ 



c 



Malarial Parasites. 



A. Tertian parasite. 1, young-form; 2-4, stages of growth and pigmentation; 
S-7, segmentation; 8, rupture of spores from corpuscle; 9, extracellular form: 
lO, flagellate form. 

B. Quartan parasite. 1-6, development and pigmentation: 7. 8, central group- 
ing of pigment and spore formation; 9, rosette of spores with nuclei; tO, extra- 
cellular form; 11, flagellate form. 

C ^Estivo-autumnal parasite. 1, ring-like body; 2, 3. amoeboid forms. 4. 
parasite in brassy degenerated red cell; 5, pigmentation. 6, segmentation; "7. 8, 
half-moon bodies; 9, flagellate forms. 



MALARIA 111 

nucleolus; i. e., segmentation occurs in the peripheral blood three 
hours before the paroxysm, which corresponds with their rupture 
from the red corpuscle into the plasma. Sporulation means death 
of the adult parasite, or its "death in childbed," as Mannaberg well 
describes it. The spores rupture through the mother cell and the red 
cell, and escape into the plasma, whence they attack and enter other 
red cells, to repeat their life-cycle. The pigment and fragments of 
red cells are picked up by the leukocytes and are carried to the liver 
and spleen. Some forms (gametocytes) do not mature nor sporulate. 
They are taken up by the mosquito, to complete in it another cycle. 
(Plate III.) 

2. The tertian organism has a forty-eight-hour cycle. In its first 
day it is small (lpt to 2fi), and appears as a bright, unpigmented, disk- 
like or annular spot in the red cell, thrusting out pseudopodia, with 
most active amoeboid movement, and possessing a relatively large 
nucleus, — partly clear chromatin, and partly chromatin which may be 
deeply stained by the Romanowsky method. It fills about one-third 
of the cell. In its second day, pigment rapidly accumulates in the 
form of fine granules or rods, which are usually peripherally located, 
and which have an actively swarming movement, compared by Lav- 
eran to that of boiling water. This is due to currents in the proto- 
plasm of the parasite. The amoeboid movement of the parasite 
decreases in twenty-four to thirty-six hours, as it grows and as the pig- 
ment increases, but some movement remains for a long time. Vacuoles 
are frequent. The parasite occupies two-thirds to three-fourths of 
the red cell, which becomes distended and chlorotic. The most com- 
mon form of the sporulation is the concentric accumulation of pig- 
ment and the development of fifteen to twenty rough, refractile spores, 
which form in two concentric circles ("sunflower" arrangement), or 
are more frequently irregular, like a bunch of grapes. . The spores 
are small and round. Sporulation occurs three hours before the chill 
and the rise of temperature, and is completed in forty-eight hours, 
when the toxins secreted produce the rigor and fever. Most spores are 
seen at the time of the chills, and even then few can be seen, because 
sporulation occurs to a greater extent in the internal organs than in 
the peripheral blood-stream. When spores are seen between paroxysms 
they represent the sporulation of another generation of parasites, too 
weak or too few to induce a paroxysm. The generations are never 
absolute as they are in the quartan type, and the parasites of the 
same generation vary six or eight hours in their cycle. This explains 
the clinical variations in periodicity. Flagellated forms may be seen 
a few minutes after withdrawal of the blood. The nodulated and 
clubbed flagella lash about and indent the red cells. They may break 
off and swim about. They occur in numerous parasites which never 
sporulate in human blood, and remain as large bodies with vibrating 
pigment. They were formerly regarded as degenerated parasites, 
but really represent gametocytes or the "sexual forms," which de- 
velop later in the mosquito. 



112 THE SPECIFIC INFECTIONS 

. 3. The cestivo-autumnal parasite has a life-cycle of from twenty- 
four to forty-eight hours. It has a very small, unpigmented body, and 
possesses most active amoeboid movement. It thus attracts early 
attention but is easily overlooked, as it possesses almost the same 
refraction as the red cell. It becomes quiet after drawing the blood 
from the body, when it appears characteristically ring-like, often with 
a central vacuole. The shape may be successively amoeboid, diskoid, 
annular, cruciform, or often may have a slight protuberance at one 
side — the seal-ring form. Mature forms contain particles of haemo- 
globin. The pigment is extremely fine, powder-like, dark, sometimes 
reddish, peripherally located, and has some movement. When the 
parasite reaches one-third the size of the corpuscle, it is usually motion- 
less, and the pigment becomes concentrated centrally or sometimes 
peripherally. Motion in the parasite has been seen in the cadaver by 
Ziemann. The spores number six to fourteen (or sixteen), are very 
small, round, and without movement or vacuoles. Sporulation occurs 
as in the other forms. Fever, pigment concentration, and sporulation, 
coincide (Golgi). If large parasites with much pigment are seen in 
the peripheral blood, they denote the onset of a paroxysm, and after 
the paroxysm, ring-forms without pigment may be observed. The 
young forms circulate in the general blood-stream, though sporula- 
tion usually occurs in the deep viscera. The half-moon bodies, or cres- 
cents, are delicate, slender, highly refractile bodies, measuring eight to 
ten microns by two to three microns, are developed in the bone-marrow 
or spleen, and possess considerable pigment, which is usually mesially 
located and has little, if any, motion. They have no amoeboid move- 
ment but may slowly change form. In shape they are spindle, oval, 
or spherical. They occur singly in the red cell. They do not mul- 
tiply in the human blood. The young crescents develop in the vis- 
cera or bone, and their adult forms are seen in the peripheral blood, 
for the periphery offers the best opportunity for leaving the body — 
through the bites of mosquitos. The male form of the crescent has 
nagella fmicrogametes) which penetrate the sexual elements of the 
female crescents (macrogametes). This occurs outside of the body, 
either on the slide or in the body of the mosquito. After several days 
crescents, spherules, or spindles, appear. Crescents indicate that the 
fever has just begun. Fever rarely occurs when crescents alone are 
found in the blood. If fever develops with the presence of crescents, 
amoeboid bodies, also, are nearly always found. The red blood-cell be- 
comes copper-colored or brassy. 

This knowledge of the parasite explains experimental inoculation 
from individual to individual as well as accidental infection during 
operations. Transmission to the foetus is unknown.' The parasite 
may be stained with methylene blue or hematoxylin, and may be 
counterstained with eosin. For the beginner, at least, study of the 
fresh blood under an oil-immersion is the best method. 

The Xocht-Romanowsky staining fluid, according to Ewing, is made 
as follows: (1) Polvchrome methvlene blue solution: To 1 ounce 



MALARIA 



113 



of polychrome methylene blue (Griibler) add 5 drops of 3-per-cent. 
solution of acetic acid (U. S. P. 33 per cent), to neutralize the undue 
alkalinity. (2) Ordinary methylene blue solution: Make a 1-per-cent. 
(saturated) watery solution of methylene blue, preferably Ehrlich's 
rectified, or Koch's, by aid of gentle heat. This solution improves 
with age and should be at least a week old. (3) Eosin solution: A 
1-per-cent. solution in water of Gru bier's aqueous eosin. Then to 10 
cc. of water add 4 drops of (3), 6 drops of (1) and 2 drops of (2), mix- 
ing well. To use, the specimens, fixed by alcohol or heat, should be 
immersed for two hours, specimen-side downward; they will not over- 
stain by twenty-four hours' immersion. They should then be washed 
in distilled water, dried slowly over the flame, and mounted in Canada 
balsam. The density of the blue may be varied to suit individual 
fancy, nor need the proportions be rigidly followed, but the accurate 
neutralization of the polychrome solution is most important. 



Mannaberg's Table: Characteristics of the Varieties of the Parasite. 
(Note. — Forms 3, 4, and 5, are usually grouped as one, sestivo-autumnal.) 





Life- 
cycle. 






Maxi- 


Form of 


Number 


Half- 


Changes in the in- 




Motility. 


Pigment. 


mum 


sporula- 


of 


moon 


fected red cor- 








size. 


tion. 


spores. 


bodies. 


puscle. 


1. 


72 


Little move- 


Coarse, 


Size of 


Daisy 


6 to 12. 


None. 


Red cells little 




hours. 


ment in the 


with lit- 


red 


form; 






changed in^size or 


Quartan 




young forms. 


tle move- 


blood 


single 






color. 


parasite. 






ment. 


cor- 
puscle. 


spores 
elongated 
and nu- 
cleated. 








2. 


48 


Active move- 


Fine 


Size of 


Sunflow- 


15 to 20 


None. 


Often hypertro- 




hours 


ment in the granules; 


red cell, er or 


(or less). 




phic. Chlorotic. 


Ordinary- 


(or less) youngest and very 


s o m e-|g rape 








tertian 


i middle-aged active, 


time s form; 








parasite. 




forms. 


"swarm- 
ing" 
move- 


larger, single 
spores, 
small, 














ment. 




round, 
and sel- 
dom vis- 
ible 

when un- 
stained. 

Irregular 








3. 


24 


In the young 


Very fine, 


1 to 1 


r. to 8 


Present 


Brassy, shrunken, 




hours 


unpigmented 


no 


of red 


particles. 


(or more). 




or sometimes 


Pigmented 


(or less) forms very 


swarming 


cell. 








wholly decolor- 


quotidian. 


active amce- 


move- 










ized. 






boid move- ment, 














ment. grow- 


forming 














ing less. 


in 
clumps. 










4 


24 


Very active 


None. 


5 t0 4 


Stellate 


6 to 8. 


Present Shrunken and 




hours. 


amoeboid 






or irregu- 




brassy. 


Unpig- 




movement. 




cell 


lar. 






mented 
















quotidian.' 
















5. 


48 


Active, per- 


M o d e r- 


ito'S 


Irregu- 


10 to 12 


Present Shrunken and 




hours . 


sisting also in 


ately fine, 


of red 


lar forms. 


(rarer 


brassy. 


Malignant 




pigmented 


often 


cell. 




15 to 16). 






tertian. 




bodies. 


shows os- 
cillating 
move- 
ment. 













114 THE SPECIFIC INFECTIONS 

(B). The Life of the Organism Without the Human Body. — King 
(1883) first suggested that the mosquito was the intermediate host 
and sole source of infection. It takes the plasmodium from man and 
reinoculates him with it after the life-cycle within its body. Other 
analogous infections are known, such as the hsemosporidia of birds, 
frogs, bats, dogs, sheep, monkeys; e.g., Texas cattle-fever inoculated 
by the tick, and the African tsetse disease (trypanosoma) in animals 
and man, which is inoculated by the tsetse-fly. Manson, especially, 
then Ross, Grassi, Bastianelli, Bignami, Daniels, Stephens, Christo- 
pher, and others, have developed this most interesting subject. The 
Plasmodium malariae has not been found except in man and in the 
mosquito. The mosquito is the primary and higher host, since the 
sexual process of reproduction in its stomach is biologically higher 
than the simple sporulation in man. The culex and the anopheles 
are the two chief genera. The culex does not contain nor convey the 
parasite. Its palpi are very short and its wings generally have no 
mottling. When sitting, its hind legs are carried above the body 
and its body lies parallel with the wall, or may sag, from the blood 
it has sucked. Its eggs are laid in tanks or puddles. It is the ordi- 
nary house mosquito and is found chiefly in cities. The anopheles 
conveys malaria. Its palpi are almost as long as the proboscis; the 
wings are mottled; the rear legs usually depend, or touch the wall, 
but sometimes are carried over the body. Its body makes an angle 
of 45° with the wall. The eggs are laid in pools or sluggish streams 
with algse growth, and the open country is its preferred habitat. In 
America, four species exist: (1) The most important is the Anopheles 
maculopennis (the Anopheles claviger of Europe); (2) Anopheles cru- 
cians; (3) Anopheles punctipennis; (4) Anopheles argyritarsis. When 
the anopheles bites persons whose blood contains sexually mature 
forms of the plasmodium (gametocytes), flagellation in the male form 
occurs and the flagella enter the female cells. After fecundation in 
the insect's stomach, the impregnated cell enters the muscular walls 
of the middle intestine, and, after two days, small, round, refractile, 
pigmented bodies appear, which, after a week, grow to 60 or 70// in 
diameter. They develop into myriads of sporoblasts which reach 
the salivary glands of the insect, whence they are again inoculated 
into man by biting. These sporozoids thus resulting from sexual 
conjugation in the mosquito, are equivalent to spores formed by asex- 
ual sporulation in the human blood. Entering the red cells in man, 
they follow the cycle of their type as above described, and produce 
either sporulating forms or sterile forms. The sterile forms in the 
human blood — i. e., the forms which do not sporulate — linger in the 
peripheral blood with the teleologic purpose of preserving and con- 
tinuing their life in the mosquito, and, on reaching its body, deyelop 
again the agents of reinfection. This knowledge concerning the mos- 
quito explains many interesting and formerly incomprehensible de- 
tails. We now know why those living in the first story of houses are 
more likely to be infected than those living in the upper floors, and 



MALARIA 115 

why those who slept in houses facing inland were infected while those 
in houses exposed to the sea air escaped, etc. In Rome, the fever pre- 
vailed just outside the Porta del Populo, while the Corso, three hun- 
dred feet distant in the city, escaped. 

Symptomatology. — (A). Fever. — Fever is, next' to the finding of 
the melanin and the plasmodium, the most constant symptom, though, 
strictly speaking, malaria should not be divided into types by the 
fever alone. It comes on after an incubation varying irregularly from 
one and a half to fifteen days. Fever bears a close relation to sporu- 
lation, as was demonstrated by Golgi, in 1885. The fever-curve is 
most variable, being very irregular in some types or almost mathe- 
matically regular in others. It is usually irregular at first even in 
regular types. It may be remittent (subcontinuous), intermittent 
(tertian, quartan, quotidian), or continuous for a few days, when it 
ends by crisis or becomes remittent or intermittent before recovery. 
The paroxysm may be delayed beyond the time when it is due (post- 
ponens), or may anticipate this time (anteponens) . There may be 
hyperpyrexia, or normal or subnormal temperature. This occurs 
in the algid variety. 

The classical divisions of the paroxysm are (1) chill, (2) fever, and 
(3) sweating, whose respective duration, according to Lorain, is in 
the proportion of 3-2-7. Any element of the paroxysm may be ab- 
sent. Thus the fever or the rigor is absent in some virulent varieties 
and in persons partly immunized, and the sweating may be slight or 
absent. The paroxysm lasts ten (four to forty-eight) hours, and in 91 
per cent, of the cases occurs between 10 a. m. and 3 p. m. Prodromal 
symptoms are fatigue, and anorexia. (1) The chill then occurs. 
It is rather sudden in its onset, often very severe, with headache, 
nausea, emesis, coldness, contraction and lividity of the skin (cutis 
anserina); the temperature by rectum is elevated, the pulse rapid, 
small, and hard; the respiration is rapid or even dyspnceic, and the 
urine is increased. The parasites are in the peripheral blood in the 
tertian and quartan types, but largely in the internal organs in the 
sestivo-autumnal type. (2) The fever is high, perhaps not higher by 
rectum than during the chill, but is more evidenced by the red, burn- 
ing skin, thirst, delirium, and headache, soft, full, or dicrotic pulse, 
and other fever symptoms. In this stage the young parasites are 
free in the blood and begin to attack new red cells. After their 
entrance into these cells the fever ceases. (3) In the sweating stage 
the young parasites are found in the red cells, and phagocytes 
take up the detritus and pigment. The sweat is usually profuse 
and somewhat characteristic, giving off an odor like that of semen. 
The patient may be exhausted, but post-febrile euphoria is usual. 

Special Febrile Types of Malaria. — The quartan and tertian 
forms are regular and intermittent, and the sestivo-autumnal forms 
are more irregular and remittent. 

1. The quartan fever is the rarest of all types ( T 8 of 1 percent.), 
is found in the temperate zones, and occupies a position geographically 



116 



THE SPECIFIC INFECTIONS 



intermediate between those occupied by the tertian and sestivo-au- 
tumnal varieties. It is caused by the quartan parasite, is the most 
regular of all types, and is called quartan because the simple form 
causes paroxysms every fourth day. The parasitic cycles are readily- 
followed in the circulating blood, and the organisms do not accumu- 
late in the internal organs. Sometimes fission bodies may be found 
without fever. The fever is rather obstinate and recurrence is fre- 



Fig. 10. 



Day 



TEMP. 

104 
















« 








102 


/ 
















\ 






100 


/ 








L_/\^ 








V 


/ 




















V 





Quartan malaria (Silvestrini). 



quent, but quinine exerts its specific action in a relatively short time. 
The type may be single, from one generation , of parasites; double, 
from two generations; or triple, from three generations, thus produc- 
ing, respectively, temperature every fourth, every first and second, or, 
finally, every day of the cycle. 



Fig. 11. 



Day 1 


2 


3 


4 


5 


6 


7 




TEMP. 

104 


















103 


"/ 








ft 








102 


/ 








A 




A 




101 


/ 








\ 




A 




103 


/ 












A 




99 


/ 






\ 


J 




7 






_J 






\ A 


^ 


- / 


^ \ 


9^ 








\S^^ 




VA 1 



Tertian malaria. 



2. Tertian fever is most frequent in the temperate zones and is the 
most widely distributed variety. It is found in all malarial countries 
and constitutes 50 to 65 per cent, of all malaria. The organisms tend 



MALARIA 



117 



to accumulate in the internal organs. Fission bodies are rarely found 
without fever. It is rarely pernicious. The type may be single, or, 
more frequently, double from two generations of parasites. Fever 
which is almost continuous may sometimes be observed (Thayer and 
Hewetson). It responds very readily to quinine or, indeed, to simple 
rest in bed (spontaneous recovery). 

3. Mstivo-autumnal fever, caused by the sestivo-autumnal parasite, 
is often irregular, remittent, intermittent, or continuous (subcontin- 
uous). It is characterized clinically by severe and recurrent fever, 
marked ansemia, frequently by absence of paroxysms (chills occurring 
in only 71 per cent, of the cases), and sometimes by pernicious symp- 
toms. It was first called sestivo-autumnal by Marchiafava "and Big- 
nami, in contradistinction to the vernal or milder spring forms. Sub- 
types: (a) Regular intermittent sestivo-autumnal fever. Its two 
varieties are: (i) The sestivo-autumnal tertian, in which the parasite 
is different from that of the ordinary tertian. The temperature is apt 
to be high, and the paroxysm doubly long. The typical curve may 



Day 


1 


2 


3 


Fig. 12. 

4 


r 


(3 


7 


8 


TEMP. 

106 


















105 


















104 




A 














103 


A 


/ 














102 


/ 


\AI 














101 


/ 


V 














100 


















99 
















\ 


















\ 


98 





































.flSsti vo-autu m n al malaria. 



be modified by the absence of a distinct initial elevation, by an ex- 
aggerated pseudo-crisis, by a briefer or longer duration of the attack, 
by anticipation or procrastination, by double attacks, and by marked 
oscillations, (ii) The sestivo-autumnal quotidian, in which the attacks 
are usually short, but have an abrupt elevation of temperature. They 
often become irregular, frequently fuse, and have fewer symptoms than 
in the other variety. This form is often mild and the patient may re- 
cover spontaneously. It may, however, become pernicious. This form 
is readily confused with typhoid, (b) The irregular intermittent sestivo- 
autumnal fever, which has marked irregular intermittency or remit- 
tency, or subcontinuous fever, because the attacks are duplicated, 
anticipated, or prolonged. The paroxysm may last twenty hours. The 
life-cycle of the parasite is often difficult to follow. The symptoms 
may be mild or very severe. 



118 THE SPECIFIC INFECTIONS 

(B). Blood-Findings. — The blood-findings are pathognomonic; viz., 
parasites, anaemia, absence of leukocytosis, and melanaemia are found. 

(a) Red Cells. — Anaemia is always present during the attack, from 
direct deglobulization by the parasite, and possibly also from liberated 
toxins. Acute anaemia is naturally more marked and rapid than in 
any other acute infection. The loss is greatest in the first attack, 
especially in pernicious cases, and sometimes reaches half a million 
cells. Reduction to 500,000 red cells (Kelsch), thus giving the pic- 
ture of pernicious anaemia, has been observed especially in cases of 
pregnancy, and in children (Frayer and Ewart). 

(b) White Cells. — In the first attack absolute and relative leuko- 
penia is observed, which is due to the collection of the white cells in 
the liver and spleen, to the destruction of the phagocytes, and, in 
cachexia, to lesions of the blood-making organs. As in other anaemias 
caused by diseases of the bone-marrow and spleen, an increase of 
lymphocytes or large, mononuclear cells, with decrease of the poly- 
morphonuclear cells, may be observed, especially in the apyretic inter- 
vals. Genuine leukocytosis in malaria denotes a complication such as 
pneumonia or sepsis. An absolute increase is sometimes observed in 
pernicious malaria, such as the " black-water fever," but even here 
the increase is in the lymphocytes. Cell division and degeneration in 
the leukocytes may be observed. 

(c) Melan^emia. — Melamemia (first observed by Virchow and 
Heschl, 1847-50) is, next to the presence of the plasmodium, the most 
constant change in malaria. It probably occurs in every instance, 
though an unpigmented sestivo-autumnal form is believed by some 
to exist. Melanaemia is present at all times during fresh infection 
and may occur shortly after the fever has disappeared, as in the half- 
moon forms. After infection it usually disappears within forty-eight 
hours. It is practically pathognomonic of malaria, though it is said 
to occur in recurrent fever, in melanotic new growths, and in Addi- 

, son's disease. It is found in the polymorphonuclears and sometimes 
in the lymphocytes. It is seen in the smaller capillary walls where 
their diameter suddenly decreases (lung alveoli, intestinal villi, appen- 
dices epiploicae, renal glomeruli, dura mater, cerebral convolutions, 
spleen, liver, and bone-marrow); the capillaries may be occluded by 
pigment. The lymph-glands are usually free of pigment, with the 
possible exception of the portal glands. Besides this pigment there 
is also the copper-colored hemosiderin. This may be found not only 
in the vessels but in the parenchyma of the liver. 

(C). Spleen. — Enlargement of the spleen (first described by Andou- 
ard, 1803), is the third important finding. It is palpable in 88 per 
cent, of the cases and is rarely anatomically absent (Laveran, Plehn, 
Kiener, and Kelsch) in tropical forms. Its size, hardness, and plump- 
ness, are proportionate to the length of the fever. They increase with its 
rise, and remit between attacks. In acute infections the spleen is increased 
three to five times its normal weight (five ounces); it is soft and friable; 
the veins are dilated, and the parenchyma is flooded with infected cells 



MALARIA 119 

and macrophagic cells; and there are sometimes areas of focal necrosis. 
The Malpighian bodies contrast strongly with the pulp. There is 
often a sticking pain over the organ, which is increased by moving 
the diaphragm. Pain is due to capsular tension, or perisplenitis, and 
is often associated with pain and tenderness in the bones. As the 
disease subsides the splenic intumescence disappears but may occa- 
sionally remain (fever-cake). In chronic infections the spleen is per- 
manently enlarged, reaching even into the pelvis. It may weigh two 
to ten pounds. The capsule is thickened, even calcified. Perisplenic 
adhesions occur and friction is frequent. Sometimes also a systolic 
murmur is heard (Griesinger). The organ is plump, the veins are 
patent, and the acute hypersemia and focal necrosis lead to increase of 
the connective tissue. The pigment, enormous at first, gradually de- 
creases. Ultimately little remains of the pulp, follicles, and splenic 
function. 

Rare complications are pressure on the intestines, nerves, and ure- 
ters, torsion of the pedicle of a wandering spleen, rupture (of which 
Choux has collated 147 cases), abscess, or perisplenic abscess. 

(D). Skin. — The skin is congested during the chill, and the vaso- 
motor constriction gives way, during the febrile rise, to hyperalgesia 
and vaso-dilatation. Miliaria appear in the sweating stage. Herpes 
is very frequent, mostly nasal or labial; erythema is not common 
except when it results from quinine or antipyrin. Erythema nodosum 
has been observed in children. Roseolas are most rare. (Edema 
occurs chiefly in chronic, and ambulant cases, and an earth-colored 
cachectic hue appears in chronic cases. The mucosas are gray but 
not pigmented. Slight icterus is not infrequent (urobilin icterus), 
and sometimes it is intense. Infrequent complications are urticaria, 
pemphigus, petechias, pigmentation, a measles-like eruption, fur- 
uncles, phlegmon, noma, gangrene, or erysipelas. 

(E). Circulatory Symptoms. — The heart is little involved, though 
sometimes myocardial degeneration and dilatation may occur dur- 
ing the paroxysm. The pulse rises parallel with the fever, small at 
first from vaso-constriction, later dicrotic and full from vaso-dilatation. 
Endocarditis is a rare development, as are angina pectoris, aortitis, 
or phlebitis. The author observed one case complicated with ulcera- 
tive endocarditis and aortitis. 

(F). Respiratory Symptoms. — Dyspnoea and pulmonary congestion 
may occur during the paroxysm. These are due to parasites and 
phagocytes accumulating in or even occluding the capillaries of the 
lung. Chronic bronchitis, emphysema, and chronic interstitial pneu- 
monia, occur as complications. Bronchopneumonia is frequent in 
malarial cachexia. Genuine lobar pneumonia occurs only as a mixed 
infection, since the malarial parasite possesses no phlogogenic proper- 
ties. Plasmodia have been seen in the sputum. Pneumonia is atypical, 
is often present without rusty sputum and without chill, and is espec- 
ially dangerous in malarial cachexia, the mortality ranging from 60 
to 78 per cent. Pulmonary tuberculosis and pleurisy are rare. 



120 THE SPECIFIC INFECTIONS 

Digestive Symptoms. — The oral mucous membrane is dry and 
metinies the seat of hemorrhage, or gangrene ■ the tongue is heavilv 
coated and the breath is foul. The parotid gland is sometimes swollen. 
The stomach may be the seat of erosions., catarrh, hyperemia, or of 
infarction with plasmodia. Anorexia, pyrosis, vomiting, and cardialgia, 
are common symptoms. Ulceration from amyloid degeneration is 
observed in only a few chronic cases. Hsrmatemesis from chronic 
splenic tumor has proved fatal. 

The Ixtestixes. — Swelling of the lymphatic structures, erosions, 
catarrh, hyperemia, thrombosis from parasite aggregation,* meteor- 
ism, constipation, and rarely diarrhoea, are observed. Acute abdom- 
inal pain is not uncommon, but occurs without obvious cause. Pain 
may simulate peritonitis. Hemorrhage is rare. The disease may re- 
semble dysentery, with ulcers in the large and small gut. Acute 
ascites may result from pylethronibosis, from plugging of the capil- 
laries by melaniferous cells, or from congestion of the peritoneum. 

The LrvER. — In acute infections the liver is swollen, hyperaemic, 
or is the seat of focal necrosis. Its endothelial cells are swollen, it 
becomes inacrophagie, and its veins are full of pigment, though as 
a rule few parasites are present. Icterus may develop from sepsis 
or red-cell destruction: it is usually polycholic. Pigmentation from 
degenerated red cells is more common than actual melanosis. In 
chronic infections the liver may weigh eight or ten pounds, is hard 
and smooth, and has a thick capsule. The changes, .seriatim, are focal 
necrosis, atrophy or partial regeneration, and pigmentation with hyper- 
a?mia. As a result of atrophy and regeneration, angioma, lymph-cysts, 
or abnormal lobules develop: hyperplasia of the perilobular connec- 
tive tissue occurs with ultimate cirrhosis. Atrophic and also hyper- 
trophic cirrhosis may follow chronic malaria Freriehs, Bamberger), 
but IMarchiafava. Bignami, and Osier, rather question its malarial 
origin, because other causes are also present. Ajnyloid degeneration 
R :kitansky . and simple atrophy from pylethrombosis and marasmus, 
are rather uncommon sequels. 

H . Genito-TJrinary Symptoms. — Polyuria is often observed dur- 
ing the paroxysm, which sometimes reaches two to four quarts, 
despite the severe sweating. The urine is usually decreased in the 
a?stivo-autumnal type. The post-malarial polyuria of convalescence 
is more frequent. In one instance the author c >served a veritable 
diabetes insipidus as described by Sydenham and Mosse. 

The urea. iron, chlorides, and specific gravity, of the urine are in- 
creased. Phosphates are decreased during the paroxysm, and increased 
afterwards. Albuminuria is present in 25 to 40 per cent, of c; 
and usually disappears with the paroxysm, but sometimes lasts two 
to three weeks, or longer. Xucleoalbumin has been found in the 
urine, besides peptone, acetone, and indican. Ehrlich's diazo reaction 
may often be obtained, in 5 per cent. Thayer and Hewitson to 40 per 
cent, in the author's experience . Glycosuria is occasional. The 
toxic coefficient is increased. Nephritis occurs in 4.5 per cent, of the 



MALARIA 121 

cases but is not often fatal. The parasites are rarely found in the 
glomeruli or veins but frequently abound in the intertubular capil- 
laries. Glomerular desquamation and epithelial exfoliation, endo- 
capsular exudation, necrosis, and cast formation, develop in the 
convoluted tubules. Chronic parenchymatous and interstitial neph- 
ritis may result from previous malarial infection. The large white 
kidney, followed by secondary contraction, is considered by some to be 
a frequent sequel. Hemoglobinuria, anuria, and uraemia, occur in 
black water fever (See Pernicious Forms). Gangrene of the genitalia 
is an uncommon sequel. Orchitis is usually due to other diseases. 
Metrorrhagia and abortions occur frequently. 

(I). Nervous Symptoms. — The parasite and its presumed toxin 
affect especially the nervous system, and for this reason von Swieten 
has called malaria a neurosis. There is scarcely a nervous symptom 
which is not occasionally observed in malaria. The sensorium, which 
is involved slightly in mild cases, may be more seriously affected in 
the more severe types, the symptoms ranging from simple exaltation 
to coma and paralysis. Headache is usual, and neuralgias are fre- 
quent, especially in the first and second branches of the fifth nerve. 
Cerebral confusion was noted by the writer in two ordinary tertian 
cases. In pernicious types especially, it is not always easy to determine 
whether nervous symptoms are due to simple toxsemia or to cerebral 
thrombosis. The central nervous tissues are usually distinctly hyper- 
semic, and are anaemic only in the algid or choleraic types. The endothe- 
lial cells of the vessels are fatty, swollen, and pigmented. Thrombosis 
in grave cases may result from swelling of the endothelium, though 
it is usually caused by the rough infected red cells. Thrombosis 
may lead to multiple small extravasations of blood. The infected 
erythrocytes never leave the vessels. 

Symptoms of paralysis (aphasia, hemiplegia, paraplegia, and mono- 
plegia), or of motor irritation (tremor, chorea, tetany, athetosis, 
contractures, epileptic attacks, or reflex spasms, such as sneezing or 
vomiting), may possibly occur in urgent types. Neuritis, neuroses, 
psychoses, spinal paraplegia with atrophy and bladder disturbance, 
ascending spinal paralysis, bulbar symptoms, symptoms resembling 
multiple sclerosis (Spiller), tabes, acute ataxia (Kahler and Pick), 
and paralysis agitans, are rare sequences. 

Special Senses. — The eyes are reddened. Herpes may, in rare 
cases, affect the cornea. Retinal hyperemia, hemorrhage or atrophy, 
neuroretinitis, or choroiditis, may occur (especially in pernicious cases). 
Otalgia, otitis media, labyrinthine vertigo, and deafness, are very 
exceptional. 

(J). Muscles and Bones. — The muscles are rarely infiltrated or 
degenerated, but are often painful. Rheumatism is infrequent except 
in India. The bone-marrow is at first fatty and pigmented; the fat 
and pigment then disappear with marked vascularization, and, finally, 
with proliferation of the marrow-cells and connective-tissue thicken- 
ing. Bone tenderness is often noted. 



122 THE SPECIFIC INFECTIONS 

Relapses. — Relapses caused by the awakening of an old infection 
almost invariably occur in all forms, and are most obstinate in the 
aestivo-autunmal type; the blood-findings are almost always positive. 
Reinfection is also frequent. 

Chronic Malaria. — Untreated infection, or reinfection, persists for 
months, especially in the aestivo-autunmal variety. It is accompanied 
by irregular fever, marked anaemia, the parasite in the blood, and 
splenic and hepatic swelling; repeated attacks always occur. In 
severe chronic cases, the malarial cachexia develops, usually after 
years of infection. It is most marked in intenselv malarial regions, 
in the aestivo-autunmal form of the infection, and in reduced subjects. 
The fever is either slight, or entirely absent; sometimes it is irregular 
and reaches 102° to 103°. The essential features of malarial cachexia 
are (1) anaemia from defective blood regeneration, with its general 
symptoms, such as oedema, rapid pulse, venous thrombosis, and 
hemorrhages in the skin, retinae, and stomach; (2) vascular changes, 
possibly due to pigment deposit, and (3) enlarged spleen and liver. 
Gangrene, chronic nervous symptoms, alimentary and respiratory 
catarrh, amyloid disease, liver hypertrophy, and extreme malnutrition, 
may occur. 

Relation to the Other Diseases. — Malaria and typhoid do not 
positively exclude each other; however, they rarely co-exist in this 
country. The detection of the plasmodia on the one hand, and 
typhoid bacillaemia or the response of the blood to the Widal test, 
on the other hand, are necessary for diagnosis. Surgical operations 
may arouse a latent malaria. Sunstroke may initiate a pernicious 
attack. Erysipelas, septicaemia, suppuration, dysentery, cholera, small- 
pox, scarlatina, recurrent fever, scurvy, and tuberculosis, may very 
infrequently co-exist with malaria. 

Pernicious Malaria. — Pernicious malaria, in the widest sense, is 
malaria which threatens life. It is characterized by severe, obstinately 
recurring fever, pronounced intractable anaemia, pernicious visceral 
symptoms, frequently by abortive paroxysms without chills, by con- 
siderable depression, tendency to recurrence, and the presence in the 
blood of the aestivo-autumnal plasmodium. Pernicious malaria con- 
stitutes but a small proportion of cases of aestivo-autumnal malaria. 
Very few pernicious cases have occurred from infection with the 
ordinary benign tertian parasite (Ziemann, French, and one case ob- 
served by the author). The pathogenesis of the pernicious type lies 
in the inelastic, irregular, infected red cells which cannot pass the 
visceral capillaries, and therefore slow the blood current. In cases of 
capillar}- hemorrhages, only the normal red cells escape from the 
vessels, and the parasite-laden red corpuscles always remain in the 
vessels. Regressional organic changes may occur in the cerebrum, 
gastrointestinal mucosa, spleen, liver, and kidney. The melanosis, 
phagocvte aggregations, and endothelial swelling are of wholly secon- 
dary importance. Accessory factors are (a) arteriosclerosis, renal 
disease, cardiac dilatation (from toxaemia), alcoholism, sunstroke, over- 



MALARIA 123 

work, malnutrition, and lack of acclimatization; (6) the number of 
parasites and their abundance in internal organs. Parasites of the 
aestivo-autumnal group, with large blocks of central pigment, usually 
indicate many plasmodia in the viscera. The parasites are often few in 
the peripheral blood or, indeed, in the blood of a splenic puncture, though 
they may be found in very great numbers in the brain at autopsy 
(Bastianelli, Marchiafava, and Bignami); (c) great activity in mul- 
tiplication may be observed even in the peripheral blood where they 
are usually less abundant during the sporulating stage. Several plas- 
modia are sometimes found in a single corpuscle; the spores may 
number ten, twenty, or even thirty; (d) increased toxicity of the 
malarial parasites is purely hypothetical, as their toxin has not yet 
been isolated; but the necroses in the spleen, liver, and kidney, and 
the great morphologic alteration in the ''brassy" red cells, are at least 
suggestive. 

1. The pernicious typhoid form (perniciosa typhosa), is inapprop- 
riately called typhomalaria. Its clinical picture is variable; chills 
are often absent ; the sensorium is involved to a variable extent, and 
depression, delirium, insomnia, headache, and backache, occur. The 
fever is atypical, intermittent, or remittent (subcontinuous), resolves by 
crisis or by lysis, and is sometimes hyperpyretic or subnormal in register. 
Quinine disturbs or breaks the type. The pulse and respiration are 
increased. Gastro-intestinal symptoms may be marked; vomiting 
sometimes of bile or blood, epigastric pain and tenderness, frequently 
tympany, and thin, dark movements of the bowels, occur. The spleen 
and liver are usually tender and swollen. An irregular bronchitis 
(sometimes dyspnoea), hemoglobinuria, albuminuria, or urobilinuria, 
are frequent. The course is usually benign, and responds to quinine; 
the mortality is 10 per cent., and, in adynamic forms, 25 per cent. Fatal 
cases usually terminate with nervous symptoms, and especially with 
coma. The differential diagnosis was impossible before the blood- 
findings were known, but was often made ex juvantibus by adminis- 
tration of quinine. Without blood examination malaria and typhoid 
may be confused; they very rarely co-exist; benign or malign malaria 
may resemble typhoid closely, with slow, dicrotic pulse, splenic tumor, 
headache, fever-curve, cerebral and abdominal symptoms, and even 
roseolse and intestinal hemorrhage; and, on the other hand, erratic 
typhoid with remittent temperature, chills, and sweats, or typhoid in 
the latter part of its normal course, may simulate malaria. 

Baccelli gives the following differentiation: 

Malaria (Subcontinua typhosa) vs. Typhoid. 

Begins intermittently. Progressively remittent. 

Remissions very irregular. Very regular, and in the morning; step- 

like. 

Temperature may be high at first. Considerable fever, reached only on the 

third or fourth day, or later. 



(Concluded on next pagej) 



124 



THE SPECIFIC INFECTIONS 



Mat.arta Subcontinua typhosia) 

Headache in beginning is rare, variable 
in site and intensity, pulsating and 
neuralgic. 

Eyes dull, subicteric from beginning. 



S t uj wose fade s dry tongue, and 
sordes, less. 

Breath nauseating. 

Delirium present from, beginning., reeure 
with temperature and other symp- 
toms. 

If lung congestion occurs, it begins sud- 
denly: foci change from lobe to 1:': e 
recurrently; dyspnoea from deranged 
circulation. 

Nervous restlessness, jactitation. 

Meteorisni can occur, but is not char- 
acteristic as in typhoid; stools darker. 



Liver congestion frequent; subicterus, 
even icterus. 

Herpes is frequent. 

Cycle, none. 

Blood: plasmodia and melanaeniia. 

R t butt ence. 

" lescence more rapid and easier. 

In adynamic: icterus, hemoglobinuria, 
leuk: : yf : as n eat anaemia. 



— . :. Typhoid. 

Early, permanent, frontal, oppress ve 
-.'..: ract eristic. 



In early stages, glistening eyes: no 

icterus. 



::;.-:-:. 



lie i ^e-like. 

3ccms zir: with advanced stage is 
constant and varies only in intens::y 

Slow development, hyposta::: 3yS- 
pnoea may rarely result from tjym- 

~ar_y. etc, 



Stupor, sopor, prostration. 

Meteorism and diarrhoea begin gradu- 
ally, and develop to a high degree; 

ochre stools. 

Less congestion, rarelv icterus. 



Rare: roseola?. 

Very typical. 

Widal reaction and typhoid be::.- 
laemia. 

Relapses less frequent. 

Tardy. 

Does not respond to quinine, which 

practically always reduces fever and 
other malarial symptoms. 



2. Of cerebral forms, the comatose [pernieiosa comatosa is the 

most frequent. Physical depression, sopor, melancholia, and impaired 
memory, may exist in the preliminary stage: later, contracted pupils, 
involuntary evacuations, lessened reflexes, or paralysis, may develop. 
The coma may be intermittent. Its second appearance is longer and more 
dangerous than the first. If the patient recovers, bradylalia, scanning 
speech, and insufficient motility of the lips or tongue, may be ob- 
served. The pulse at first is generally slow and regular, but as death 
approaches it becomes soft, thready and rapid. Death is usually 
cardiac. The respirations vary, being quiet or noisy, hurried, or of 
the Cheyne-Stokes type. If fever is present it is irregular. The 
author has seen four such cases in Chicago. Apoplexy, uraemia , and 
sunstroke, must be considered. The splenic tumor per se suggesxs a 
blood examination. The " meningeal type" occurs especially in chil- 



MALARIA 125 

dren, and in these cases the slow pulse, headache, rigid and tender 
neck, sopor, convulsions, involuntaries, hyperesthesia, and ultimate 
coma, can be correctly interpreted only after a blood examination. 
Delirium may be the main symptom, and may appear as a mania, 
as fixed ideas, hallucinations, or as melancholia. The rare convulsive 
tvpe may be (a) generalized, and may simulate tetanus, hysteria, 
uraemia, or epilepsy especially in children, or (b) localized, with such 
symptoms as contractions, trismus, eye deviations, or opisthotonos. 
The paralytic form is the least frequent type. Hemiplegia with aphasia 
is more common than monoplegia, focal paralysis, or the bulbar 
form. 

3. The algid pernicious type occurs with cyanosis, collapse, Hippo- 
cratic expression, and marked alimentary symptoms, early death being 
the rule. 

4. The pernicious g astro-intestinal variety is most frequent next to 
the cerebral type, and occurs with vomiting, pain, epigastric distress, 
cardialgia, icterus, and dysenteric manifestations. In a soldier from 
Cuba, the author observed profuse hemorrhages from the bowel. A 
prompt response to quinine followed the detection of the aestivo- 
autumnal plasmodium. 

5. The pernicious biliary fever ("jungle fever") occurs with vomit- 
ing, polycholia, icterus, nervous symptoms, hemorrhages, adynamia, 
oedema, and dark albuminous urine. The course is usually ten to 
twelve days, but even after the administration of quinine this type 
may be lethal. The blood examination differentiates it from yellow 
fever. 

6. The hemorrhagic types resemble WerlhofFs disease, and scurvy. 

7. The febris biliaris hcemoglobinurica ("black-water fever") occurs 
in South America, in Africa, and in our Southern States. The factors 
in its production are syphilis, alcoholism, repeated malarial attacks, 
exposure to changes in climate, undue exertion, and cold, as well as 
local influences, and in some instances the use of quinine. Stephens 
(1903) in 95 cases found the parasite in 96 per cent, before, and in 62 
per cent, at the onset of the attack. The etiological role of quinine is 
questioned, but some other factor is apparently more potent. The 
cardinal symptoms of this type are (a) hemoglobinuria; the urine is 
always albuminous, neutral, or alkaline, in reaction; haemoglobin is 
detected only after the destruction of at least one-sixth of the circu- 
lating red blood corpuscles; (b) icterus, invariable except in the mildest 
cases; (c) irregular fever; (d) the detection of the plasmodia. The 
mortality (40 to 50 per cent, of the cases) is due to syncope, hemorrhages, 
anuria, and coma. 

Diagnosis. — 1. From Symptoms. — A probable diagnosis can often 
be made, as, for instance, from typical intermittent fever which occurs 
early in the day and is distinct from the vesperal hectic or septic fever. 
The three elements of the paroxysm are most marked in the benign 
malaria. In the sestivo-autumnal form the chills may often be absent. 
Splenic enlargement, pain, and herpes, are always suggestive, but 



126 THE SPECIFIC INFECTIONS 

they also occur frequently in ephemeral fevers, acute gastritis, pneu- 
monia, meningitis, rheumatism, and influenza, and more rarely in 
typhoid, tuberculosis, and tuberculous meningitis, Much emphasis 
was once placed on various intermittent manifestations, such as neu- 
ralgia, vertigo, herpes zoster, and alimentary and respiratory catarrh. 
To-day equal skepticism is properly entertained in regard to their 
malarial origin. 

2. The Diagnosis ex Juvantibus. — Laveran excluded malaria, 
when the fever persisted for more than four days, with the daily ad- 
ministration of 20 to 30 grains of quinine. In tropical forms more 
quinine may be necessary for this purpose. It must be remembered, 
however, that other diseases than malaria may subside under the ad- 
ministration of quinine. 

3. The Plasmodium. — Mistakes in interpretation are possible. 
The plasmodium may be mistaken for vacuoles resulting from mechan- 
ical injury to the red cells; it may be mistaken for particles of im- 
mersion oil which may reach the specimen; or for retraction of the 
haemoglobin, which may show the stroma of the corpuscle, and for poi- 
kilocytosis. Possibly less mistakes are made when the inexperienced 
observer examines the fresh blood. The plasmodium may also be con- 
fused with swarming particles from the red blood-cells, or with blood 
plates which are sometimes mistaken for spores. The differentiation 
from these is easily made in the stained specimen. Leukocytes con- 
taining pigment are distinguished by their large nucleus and by their 
amoeboid movement, the latter of which is lacking in plasmodia suffi- 
ciently large to cause confusion. 

Positive Findings. — The malarial parasite is found in the blood 
of malarial patients only. Osier found them in every instance, in 
531 cases. It is usually stated that they occur in largest numbers 
before or at the time of the paroxysm, though it must be admitted 
that the first examinations in early fever are often negative. Previous 
administration of quinine may render the findings obscure. Melan- 
aemia is practically pathognomonic. Pigment lying free in the plasma 
is of no importance, for even the greatest care will not eliminate the 
possibility of contamination. 

Negative Findings. — These are of relative value only, and depend 
upon the skill of the observer, and the time of the examination. In 
BaccehTs series there were negative findings in only 2 percent, of the 
cases. If plasmodia are not found in the circulating blood, the spleen 
may be punctured — a proceeding, which is not without danger. Ste- 
vens regards an increase of the large mononuclears to 20 per cent, 
as a safe sign. 

Differential Diagnosis. — 1. From typhoid fever (see Pernicious 
Malaria and Typhoid). 

2. In sepsis (see table under typhoid), pyaemia, ulcerative endo- 
carditis, liver abscess, septicopyemia, hectic pulmonary phthisis, sup- 
puration in the intestinal and urinary tracts, and irregular fever, may 
be confounded with malaria. However, we find in malaria the plas- 



MALARIA 127 

modiura, melanaeinia, response to quinine, and absence of leukocytosis; 
whereas in sepsis, leukocytosis, positive blood cultures, and septic 
localizations, are very frequent. 

3. Pneumonia with remittent curve, irregular grippal temperature, 
and hysterical fever; gastro-intestinal catarrh; Malta fever; recurrent 
fever; miliary tuberculosis; fever in malignant new growths and 
especially in sarcomatosis ; filarial infection; pernicious anaemia; 
splenic anaemia; leukaemia; pseudoleukaemia; Weil's disease; and 
acute febrile jaundice, may be confused with malaria, if careful and 
repeated blood examinations are not made. In Weil's disease, mus- 
cular pains, especially in the calves, and decolorization of the stools, 
which are usually polycholic in malaria, are suggestive. Pernicious 
malaria (v. s.) may superficially simulate apoplexy, sunstroke, menin- 
gitis, cholera, dysentery, or purpura. 

Prognosis. — The degree of infection, type of parasite, reinfection, 
health and habits of the individual, and antecedent renal or cardiac 
disease, are the most important considerations. The prognosis must 
be conservative in pernicious and cachectic forms. In Italy the yearly 
death-rate is 54 per 1,000, and the French lost 6,000 soldiers in Mada- 
gascar in three months. On the other hand, fully 20 per cent, recover 
when given rest in bed and a full diet, as is often shown in cases 
which are treated with placebos, and saved for clinical demonstrations. 
Spontaneous recovery is not yet fully understood. The factors are 
the phagocytes in the spleen, in the bone-marrow, and, to a less de- 
gree, in the endothelium of the splenic, hepatic, and cerebral vessels, 
Kupfer's cells in the liver, and possibly the leukocytes which are 
usually decreased in other than pernicious types. 

Treatment. — 1. Prophylaxis. — Prophylaxis now embraces more 
than personal prevention. In Italy and other countries it is a national 
economic problem. Drainage, the filling in of stagnant pools and 
swamps, and the planting of pines, eucalyptus trees and sugar-cane, 
have proved most successful, though sometimes accomplished at great 
sacrifice of life. The drainage of the great Bordeaux swamp in 1805 
cost 3,000 lives. In digging canals or building roads, immunes should 
be employed, but whites may work successfully if they avoid exces- 
sive labor in the hot sun, alcohol, and exposure to the night air. Noc- 
turnal infection by mosquitoes may be minimized by using nettings 
on the doors and windows. The pools where the insects breed should 
be filled in, or covered with crude petroleum to kill the larvae. The 
stocking of semistagnant streams with fish is also of value. The 
prophylactic use of quinine in daily doses of 5 to 10 grains is effective. 

2. Specific Treatment. — Quinine is one of our few specifics. It 
has been used for ages in Peru. The plant was known as the "tree 
of health" to Pizarro in the conquest of Peru. Quinine was intro- 
duced over one hundred years later into Europe by del Vego (1640). 
It acts on the malarial organism while it is developing (Marchiafava 
andBignami) ; when the parasite has transformed all the haemoglobin into 
melanin, and segmentation begins, quinine is ineffectual. All such 



128 THE SPECIFIC IXFECTIOXS 

malarial manifestations as fever, acute splenic tumor, and anaemia, 
are cured by quinine except in pernicious forms. It acts as a 
direct protozoan poison. Binz thought it entered into such close 
union with the haemoglobin that the parasite was suffocated. Just as 
syphilitics tolerate much mercury and iodide, so malarial subjects 
escape many or all of the symptoms of cinchonism, such as tinnitus 
aurium, cephalic distention, and slight deafness resulting from thera- 
peutic doses (gr. x.); deafness, disordered vision, flushed face, and 
cerebral congestion (sometimes relieved by epistaxis), vomiting, stag- 
gering, giddiness, tremor, and twitchings, resulting from larger doses, 
and stupor, delirium, cardiac oppression, complete deafness, and amau- 
rosis, dilated pupils, convulsions, paralysis, hemoglobinuria, dyspnoea, 
coma, weak heart, or hemorrhages resulting from ordinarily toxic 
doses. 

Administration. — If idiosyncrasy exists, cinchonism is lessened by 
ext. ergotae fl. qss, or, better, by sodium bromide 3 SS - Its antiperiodic 
action is enhanced by combining it with opium gr. ss. Such laxatives 
as cream of tartar and calomel are unnecessary. Pills are often in- 
soluble, and the dose is therefore given in capsules, in powders in- 
volved in starch wafers, or with one drop of sulphuric acid to each 
grain of the sulphate. Chloroform, coffee, cognac, and extract of gly- 
cyrrhiza, but poorly disguise its bitterness. If the stomach rebels, a 
warm-water injection with equal parts of quinine and tinct. opii de- 
odorat. may be used. In severe cases double the ordinary dose of the 
bimuriate of quinine and urea (Quininse carbamas bichlorida) should 
be used hypodermatically, but, though every care be taken, abscesses 
develop too often. In comatose and other pernicious types, Baccelli 
injects quinine intravenously (sterilized solution of sodium chloride, 
quinine muriate, and water, in the proportion of 1, 10, and 100, parts 
respectively) . 

Time of Exhibition. — If the fever recurs regularly, grs. x. to xx. 
should be given in the interval to act on the growing voting forms in 
the red cells, and this should be repeated in three to five hours before 
the paroxysm, in order to have the drug in the circulation when the 
spores are scattered (Torti and Golgi). If the fever is continuous or 
sub-continuous, or if the type is severe, doses of the same amount 
should be given daily. Large doses are recommended because thev are 
more effectual, the symptoms are frequently severe, and small doses 
are quite useless and sometimes only serve to aggravate existing malaria 
and develop quiescent forms (Steudel-Kuchel). Opinions vary as to 
the treatment of black-water fever; one view maintains that it is 
caused by the parasite, and another that quinine is its cause. Quinine, 
however, should be given only when plasmodia are found, and should 
be withheld after they disappear. 

3. Symptomatic Treatment of the Paroxysm. — During the vaso- 
constriction of the chill, morphia gr. \ and nitroglycerine gr. 50, 
hypodermatically, and spirits of chloroform 5 j., in hot whiskey and water 
afford great relief. The fever is short-lived and requires little inter- 



SEPTIC AFFECTIONS 129 

ference other than the ice-bag or cap, and cool sponging. The sweat- 
ing requires no treatment. A weak heart should be supported by 
morphine, strychnine and camphor by the hypodermic needle, heat 
and saline enemata or infusions. 

In chronic malaria, iron and full increasing doses of arsenic should 
be combined with quinine. Arsenic is said by Durham to act on the 
gametocytes. 

The contraindications to the use of quinine usually listed, (gastro- 
intestinal inflammation or irritation, middle-ear, genito-urinary, and 
cerebral inflammation,) are negligible in the treatment of malaria. 

SEPTIC AFFECTIONS. 

Synonyms. — Sapraemia, septicaemia (sepsis), pyaemia, septicopyae- 
mia. 

Definition. — Intoxications are the result of the absorption of sub- 
stances which are elaborated for the most part by microorganisms, 
but possibly also to a less degree by living cells. Infections are always 
due to microorganisms. Sapraemia is the absorption of putrescent 
substances but not of the germs which develop them. Septicaemia 
(sepsis) is the presence in the blood of microorganisms (bacteriaemia), 
which are usually pyogenic, without hematogenous suppuration or 
metastasis. Pyemia is infection, caused by microorganisms, which 
leads to haematogenous metastasis or suppuration. Septicopyaemia is 
coexistent septicaemia (bacteriaemia) and pyaemia (metastatic suppu- 
ration). 

General Groups. — 1. Some infections — such as carbuncles, puer- 
peral parametritis, diphtheria, and tetanus — are wholly local so far 
as the causal microbe is concerned, and their symptoms are due to 
absorbed toxins, toxinaemia (toxaemia). 

2. Other infections — such as typhoid, pneumonia, carbuncles, 
puerperal sepsis, anthrax, and gonorrhoea, which cause bacteriaemia 
or septicaemia — at first local, may become general when their germs 
enter the blood. Some of these infections, especially typhoid and 
pneumonia, which were previously considered local, are always general. 

3. Still other infections, often resulting from the same germs, 
cause metastatic suppuration (pyaemia). Among these are multiple 
abscesses from carbuncle, puerperal fever, typhoid osteomyelitis, 
pneumococcic arthritis, and gonorrhceal endocarditis. It is frequently 
difficult or impossible to preserve clinically these types which so often 
blend; (a) what is seemingly toxaemia may prove bacteriaemia on 
examination of the blood; (b) apparently pure bacteriaemia may 
prove pyaemia at necropsy; (c) all three grades may occur successively ; 
(d) the primary infection — e. g., with scarlatina, tuberculosis, and 
diphtheria — whether local or general, may be complicated by second- 
ary, or mixed infection, especially by the streptococcus; (e) again 
the symptoms vary, first with the variety of microbe and its virulence ; 

9 



130 THE SPECIFIC INFECTIONS 

second, with its localization (in the throat, lung, pelvis, etc.) ; and third, 
with the physiological resistance. Subjects of malignancy, cardiac, 
vascular, nephritic, cirrhotic, and other disease, readily succumb to 
an ultimate sepsis to which the name of terminal infection is applied. 
For these reasons we will discuss septic infections as a whole, and indi- 
cate such special etiological and clinical variations as seem necessary. 

Etiology of Septicopyemia. — The causal organisms of septic in- 
fections are numerous. The most common are the pyogenic cocci, 
the pneumococcus and the colon bacillus; less frequent are the gono- 
coccus, anthrax bacillus, typhoid bacillus, Friedlander's pneumo- 
bacillus, meningococcus, bacillus pyocyaneus, influenza bacillus, gas 
bacilli (FraenkePs bacillus phi egmonesemphysematose; bacillus aerog- 
enes encapsulatus), and possibly the micrococcus tetragenus, the 
spirilli and bacilli of Vincent, and the proteus group. Although puer- 
peral fever, primary wound fever and severe late pyemic infection 
were known to Hippocrates, and also to Willis (1682), Semmelweiss 
(1847), and others, it was reserved for the bacteriological era, build- 
ing on Virchow's work, to clarify this group of affections. Though 
Wunderlich (1847) spoke of spontaneous pyaemia, and Leube (1878) 
coined the term cryptogenetic (occult) septicopyemia, careful clinical 
and necropsy investigations have gradually revealed the atrium of 
infection. Although some cases are still obscure, the source of infec- 
tion is now found in 90 to 94 per cent, of cases; (1) skin lesions, such 
as acne, furuncles, felons, and bites, (staphylococcus most frequent; 
less often streptococcus); (2) throat (streptococcus); (3) nose (not 
frequent in sepsis, though probably the atrium in meningitis for the 
meningococcus and pneumococcus); (4) ear (pneumococcus and 
streptococcus); (5) lungs (pneumococcus); (6) intestines and bile 
tracts (colon bacillus; typhoid bacillus, gall-stones with infection, ap- 
pendicitis, dysenteric ulcers); (7) urinary tract (pyelitis from colon 
bacillus; vesical and urethral infections chiefly by the staphylococcus, 
far less by the streptococcus and gonococcus) ; (8) vagina and uterus 
(chiefly streptococcus). 

General Pathology and Symptomatology. — (A.) General Toxaemic 
Symptoms. — 1. Fever. — Fever is usually the first clinical symptom 
and occurs more often abruptly than gradually. The virulence of 
the germ and its toxin (rather than its variety) governs the intensity 
of the toxemic symptoms. In general the fever tends to be remittent 
or intermittent. Lenhartz, in his work on septic infections, concludes 
that (a) the streptococcus infections usually produce irregular inter- 
mittent fever with moderate variations (sometimes remittent or in 
severe cases continuous fever); (b) the staphylococcus usually causes 
weakly remittent or continuous fever; (c) the pneumococcus produces 
remittent or continuous fever; (d) the colon bacillus and gonococcus 
cause intermittent fever with great variations. Fever may be absent 
in very severe forms, especially before death. 

2. Chills. — Chills occur both in septicemic and in pyemic forms, 
are usually irregular, but may occur daily or two or more times a day. 



SEPTIC AFFECTIONS 131 

3. Nervous Toxcemia. — Nervous toxaemia may be pronounced. It 
may appear as unrest, delirium, sopor, convulsions, dry tongue, and 
the status typhosus, or it may resemble meningitis. The brain may 
be clear, as it is in many puerperal infections. 

4. Vasomotor and cardiac weakness, with increased, often irregular, 
pulse, may be present. 

5. Increased respiration and bronchitis may be noted. 

6. Albuminuria and acute nephritis are common. 

7. Septic diarrhaa, in which the dark movements number six to 
ten daily, may be observed. 

8. Acute splenic tumor is present. 

9. Anatomically we find cloudy swelling of the heart, liver, and 
kidneys; a vascular, soft, moderately swollen spleen; often acute 
nephritis; hemorrhages into the skin, retina, and mucous and serous 
membranes, with or without bacteria; lung oedema, and, where there 
is marked anaemia, fatty heart, hemorrhage into the bone-marrow, 
and increased iron deposit in the liver. 

(B.) Blood-Findings. — 1. Bacteriamia is found in 50 per cent, of 
the cases clinically, and in 95 per cent, at autopsy (Lenhartz). Some 
circulating bacteria are apparently killed by the blood. In most 
streptococcic and staphylococcic infections, these organisms are found 
in the blood. 

2. Polymorphonuclear leukocytosis is frequent, though not invariable. 

3. Anoemia — Marked anaemia is usual, and sometimes even re- 
sembles the pernicious form. 

(C) Metastases. — They are apparent clinically, or first found at 
necropsy. Metastases occur through the veins or lymph-vessels. 
Thrombo-phlebitis develops at the seat of primary infection, and dis- 
integrated thrombi, containing bacteria, escape into the venous cir- 
culation. They lodge in the lungs or, passing them, reach the left 
heart and arterial system. Purulent lymphangitis may, in the same 
way, cause metastatic suppuration. If "end arteries" are plugged, 
infarcts result; if the arteries are not terminal, small foci develop. 
Not all the infarcts suppurate. This difference is explained by the 
fact that the germs found in them are less virulent, or that the embolic 
material is bland or free of microbes. Foci occur in organs in which 
there are end arteries and in which the circulation is slow, especially, 
therefore, in the liver, kidney, and spleen. (1) Cerebral metastasis may 
cause meningitis, brain abscess, or extensive softening (encephalo- 
malacia with aphasia and hemiplegia). (2) Cardiac metastasis de- 
velops in 21 (even 63) per cent, of the metastatic group; endocarditis 
is localized chiefly on the mitral (62 per cent.) and aortic (22 per cent.) 
valves; it is attended by a heart murmur in 60 per cent., and often by 
pericarditis; the heart muscle is sometimes the seat of abscesses. (3) 
Lung localization may cause multiple or single abscesses, and often 
sero-fibrinous or purulent pleurisy. 4) Renal localization may result 
in nephritis or suppurating infarcts, with albuminuria, cylindruria, 
pyuria and bacteriuria. (5) Splenic localization usually results in en- 



132 THE SPECIFIC IXFECTIOXS 

largement, frequently in pain, and rarely in perisplenic friction. (6) 
Localization in the bones, may cause early fugitive bone pain, or 
later, fixed osteomyelitic tenderness over one or more bones, with in- 
flammatory signs; in the joints (as in the post-febrile arthritides), it 
may cause simple pain, or serous or purulent synovitis; in the muscles 
it may produce abscesses, purulent oedema, or Wagner's polymyositis. 
(7) Localization in the skin may cause scarlatiniform, morbilliform, 
roseolous or urticarial eruptions, resembling the antitoxin rashes. 
Ecchymoses occur in 50 per cent, of fatal cases; they are usually late, 
often symmetrical, and sometimes occur on the tip of the nose, fin- 
gers, toes, or ears. Pustules and vesicles are less frequent; herpes 
occasionally develops. (8) Localization in the eyes may produce 
retinal ecchymoses (in at least 33 per cent.), which were first described 
by Litten. They are round, or irregular, or appear in streaks; they 
often have white centers (which are usually small), range in number 
from three to six, and appear late or just before death; the white 
spots of Roth (8 percent.) were once considered inflammatory, and are 
still unexplained. Least frequently eye localization results in pan- 
ophthalmitis, of which 33 per cent, is due to ulcerative endocarditis. 
(9) The peritoneum is chiefly involved in puerperal forms. (10) The 
slightly enlarged liver is more often due to toxic parenchymatous 
degeneration and cardiac weakness than to abscess, which occurs 
(Baerensprung) in only 15 per cent, of cases of surgical septicopyemia. 
Intestinal infarction is rare. 

Special Symptomatology.— This may be considered etiologically or 
topographically. To avoid repetition, only the leading characteristics 
are presented. 

(A). Etiological. — 1. Streptococcic infection is the most frequent 
primary and secondary septic infection. It constitutes 66 per cent, 
of all forms (Mau), and is said to enter the blood before death in 33 
per cent, of all fatal diseases. Its atrium is most often the throat 
and (in the female) the genitalia; it enters the veins (in puerperal 
infection) more often than the lymphatics (erysipelas and puerperal 
sepsis); it more often produces septicaemia (65 per cent.) than pyaemia 
(35 per cent.); the lungs are usually unaffected; endocarditis occurs 
in 7 per cent. ; its course is chiefly acute, though sometimes subacute 
(ulcerative endocarditis). 

2. Staphylococcic infection usually enters by the skin and the fu- 
runcle is the typical primary local lesion. On the eye-lids, nose, or lips, 
this lesion is dangerous because infection may reach the facial vein, 
then the ophthalmic vein and the cavernous sinus. Furuncle of the neck 
may reach the transverse sinus. Infections of the skin are the most 
frequent cause of osteomyelitis. Meningitis is known to have followed 
a felon. The infection enters through the throat, first with difficulty 
but then with increased malignancy (Kocher and Tavel). It travels 
by the veins or lymphatics; it produces metastasis in 95 per cent, 
and endocarditis in 6 per cent, of the cases. Abscesses of the lung 
and kidneys are very frequent; the coccus is found very often in the 



SEPTIC AFFECTIONS 133 

blood and urine. Pustular skin eruptions are frequent. Staphylo- 
coccic infection is usually acute. 

3. Pneumococcic Infections. — In all cases of pneumonia (q. v.) 
the pneumococcus appears in the blood (pneumohsemia). In sepsis 
following pneumonia, it is assumed to enter the blood through the 
pulmonary veins. Infection through the ear or bile-tracts is less fre- 
quent; metastases occur in 25 per cent, and endocarditis in 6 per 
cent. Twenty-nine cases of meningitis were first reported by Nau- 
werk (1881), but it is yet unknown why lung infections so frequently 
cause brain metastases. The pneumococcus alone may produce pus 
in the joints, skin, thyroid, and serous membranes. Netter's state- 
ment that pneumococcic sepsis is less severe than other types may 
be true in some cases, but it is often malignant. It may be associated 
with the pyogenic cocci, or saprophytes. 

4. Colon sepsis, which is less frequent, may follow wounds, suppu- 
ration in cholelithiasis, cystitis, pyelitis, or intestinal obstruction. 
Endocarditis is exceptional, and sepsis (78 per cent.) is more common 
than metastasis (22 per cent.). As the intestine is its normal host, it 
is sometimes regarded as an autoinfection. 

5. Gonococcic infection is rather more benign than the other types. 
There may be gonorrhceal endocarditis (Bordoni, Uffreduzzi) (of which 
Loeb has collected 62 cases), pericarditis, and pleuritis, or the more 
common gonorrhceal "rheumatism." Thayer found the gonococcus 
in the blood (v. Gonorrhceal Infection). 

Other forms are less frequent. These are the typhoid sepsis (typhoid 
suppuration in the pleura, thyroid, bones, meninges, muscles, ear, and 
parotids), sepsis from Friedlander's pneumobacillus,and the meningo- 
coccus. Pyocyaneus sepsis is attended by irregular or continuous 
fever, rapid pulse, vomiting, diarrhoea, and a hemorrhagic diathesis. 

(B). Topographical. — (1) Ulcerative endocarditis; (2) cholangitic 
sepsis; (3) otogenous sepsis (v. Sinus Thrombosis, Meningitis, Brain 
Abscess) will be considered elsewhere. The two following surgical 
or obstetrical localizations are of importance to the general prac- 
titioner and internalist. 

(4.) Osteomyelitis is either a solitary metastasis or part of a general- 
ized sepsis. Even when a solitary bone is involved, the blood often 
contains the causal microorganism. It is due to the staphylococcus 
chiefly, then to mixed infection with the streptococcus, which is found 
in all fatal cases, or with the pneumococcus, and but rarely to the 
typhoid organism. Fraenkel has recently found that in most autopsies 
on typhoid and pneumonia cases, their causal bacteria are present 
in the bone marrow. Acute forms of osteomyelitis are most frequent 
in the growing bones of children. Trauma is a promoting element, 
and the onset occurs with chill, fever, vomiting, diarrhoea, head- 
ache, and bone pain. It is usually first seen (and often mistaken) 
by the general practitioner. Chronic forms are quite infrequent, 
but Kocher, Jordan, and others, have described cases, which, lasting 
one year or more (even thirty), may simulate sarcoma, or syphilis. 



134 THE SPECIFIC AFFECTIONS 

(5.) Puerperal fever is caused by the streptococcus (95 per cent.) or 
by the bacterium coli, staphylococcus, gonococcus, proteus, or anae- 
robic organisms. It is still disputed whether streptococci normally 
reside in the healthy vagina and whether autoinfection may occur 
from this source, but some cases seem clearly proved. It is sporadic 
or epidemic; it is promoted by anaemia; some women, however, 
seem immune, especially those in the lower classes (De Lee). Its 
varieties are (a) toxcemia, or sapramria. The symptoms are caused 
by toxins or putrid decomposition products respectively. Even in 
cases apparently of this group, bacteriaemia may be found (colon bacil- 
lus, saprophytes, or streptococcus). The rare puerperal tetanus is 
wholly toxaemic. (b) Lymphangitic form — Lymphangitis, from in- 
fected vaginal or cervical wounds, may cause moderate parametritis, 
which is usually a benign local infection. The usual forms are: 1. 
General septicaemia, from vaginal or cervical wounds, which follows 
the lymph-vessels through the cellular pelvic tissue to the general 
circulation. The symptoms usually appear within a day or so after 
delivery. Death may result (in two to fourteen days), or encapsulation 
(the important prognostic element) may last over a month with mas- 
sive cellulitis. 2. Lymphangitic peritonitis is more frequent (about 20 
per cent, of fatal cases). It begins three or four days after delivery and 
is usually generalized and suppurative. Infection may travel directly 
to the peritoneum or, more often, by retrograde lymphatic routes. This 
form includes Virchow's " erysipelas grave internum puerperale." It is 
more common in labor at term than in abortion. The symptoms are 
chill, fever, tense pulse, vomiting, peritoneal pain, distention, and often 
effusion, and diarrhoea. In many apparently purely peritonitic cases 
bacteriaemia is found. Early death is the rule, commonly in five to 
six days, but encapsulation is possible. 3. The thrombophlebitic 
(pyaemic) type occurs in 50 per cent, of fatal cases. It usually begins 
in endometritic ulceration, diphtheria, or ichorous inflammation, in 
contradistinction to the lymphangitic form of vaginocervical origin. 
Infective thrombophlebitis travels (a) from the upper veins by way 
of the spermatic veins, of which the right empties into the inferior 
cava and the left into the renal vein; the phlebitis may actually ex- 
tend into the vena cava; (b) from the lower plexus, by way of the 
uterine veins into the hypogastric (less often the obturator) veins, and 
thence to the inferior cava. Bilateral venous thrombosis is common 
(25 to 66 per cent.) Metastases are common; 58 per cent, occurs 
in the lungs, 25 per cent, in the kidneys, 20 per cent, in the joints and 
muscles, and 16 per cent, in the spleen. Ulcerative endocarditis, 
panophthalmitis, and suppurative peritonitis, may be present. It is 
unknown why the brain is so often unaffected in this form. The 
course may be stormy from predominating toxaemia, or slower with 
metastasis. The fever is irregular, the pulse rapid, the chills 
severe, the anaemia marked, and bacteriaemia is present (strepto- 
coccaemia in over 90 per cent.). 



SEPTIC AFFECTIONS 135 

Diagnosis. — The differentiation from typhoid, malaria, and miliary 
tuberculosis, is fully considered under typhoid fever. In typhoid, the 
bacillaemia (85 to 95 per cent.) and the Widal test (95 per cent.) are 
decisive. In septicaemia, bacteriaemia is present in 50 per cent, of the 
cases. In malaria, the plasmodium is absent in less than 1 per cent., 
and quinine is successful at once. In miliary tuberculosis, the choroidal 
tubercles (possibly confused with Roth's white spots), and tubercle 
bacilli in the blood are the only positive criteria, though unfortunately 
they are infrequent. Retinal hemorrhages argue for septicopyemia. 
Septic pseudorheumatism rarely needs to be confused with true multiple 
articular rheumatism. Bacteriaemia, or organisms in the fluid of the 
joints, is never genuine rheumatism. Uraemia; secondary (terminal) 
infections in cardiac, arterial, renal, and hepatic disease; mixed infec- 
tion in tuberculosis; fever in Hodgkin's disease; carcinosis; or sar- 
comatosis, may sometimes cause confusion. 

Prognosis. — The prognosis depends upon the organism, its virulence 
and dissemination, the patient's physiological resistance (whence the 
obviously poor outlook in terminal infections), and finally on the sur- 
gical accessibility of the primary lesion or metastatic foci. Only 17 
per cent, of Lenhartz's cases with bacteriaemia recovered. A stormy 
onset and chills are ominous. A case of Lenhartz with empyema, 
lung abscess, panophthalmitis, diffuse venous thrombosis, and multiple 
osteomyelitis, recovered. Puerperal infections, with the large wound- 
surface and frequent hemorrhages, are severe, the mortality of all 
forms being 55 per cent., and of severe forms 65 per cent. (Cursch- 
mann). The streptococcus has been regarded with particular dread; 
however, Bertelsmann (1904) states that the prognosis is twice as 
favorable as in staphylococcic invasion. 

Treatment. — Surgical prophylaxis, even in apparently insignificant 
wounds, and obstetrical asepsis, are important, especially in subjects 
reduced by general diseases. Treatment of existing sepsis consists 
in giving the largest possible amount of food which can be digested; 
in free administration of water~and-salt solution by rectum or by 
transfusion, in order to flush the toxins through the kidneys; and in 
the free use of alcohol, given as it is in typhoid or pneumonia, but in 
its maximum dosage because the patient exhibits an exceptional 
tolerance to the drug and unquestionable benefit results. The treat- 
ment of hypostasis, diarrhoea, vomiting, and chills, is symptomatic. 
The temperature is seldom influenced by drugs, though quinine (see 
Pneumonia) may most safely be given. The internal use of germicides 
is justly abandoned. We have not observed the slightest benefit from 
Crede's silver ointment, though others think it very beneficial ; C rede's 
collargol has been used with benefit, intravenously, in doses of one to 
two and a half drams. Nuclein and 5j to 5*j of fresh brewers' yeast 
are also advised. The use of Marmoreck's antistreptococcic serum 
has given no essential reduction in the death-rate, and its suggestive 
effects in isolated cases is easily misleading. Lenhartz has used a 
serum from the blood of convalescents from septic cases with some 



136 THE SPECIFIC IXFECTIOXS 

success. Surgical intervention is indicated whenever definite accessi- 
ble foci are localized. 

PNEUMONIA. 

Synonyms. — Fibrinous pneumonia, croupous pneumonia, lobar 
pneumonia, pleuropneumonia, pneumonitis, lung fever. 

Definition. — An acute infectious disease caused by the pneumo- 
coccus (and occasionally by other bacteria), self-limited in its course, 
characterized by inflammation of the lung (filling of the alveoli, and 
often of the bronchioles, with a fibrinous exudate), by involvement of 
considerable areas (lobar pneumonia), by toxaemia, by pneumococ- 
caernia (pneumococci in the blood), and by solution of the fever by 
crisis. It is not uncommonly complicated by secondary infective pro- 
cesses. 

Frequency. — Pneumonia constitutes 6.5 per cent, of all internal 
diseases, 3 to 4 per cent, of all diseases, 6.6 per cent, of all deaths 
anions medical cases (Liebermeister), and 8 per cent, of all deaths 
(E. F. Wells). 

That it is a specific injection is proven (1) by its frequent endemic, 
epidemic, or even occasional pandemic, prevalence. It may haunt 
certain dwellings or break out in hospitals, asylums, or prisons; (2) 
by the great frequency or constancy of the pneumococcus in the 
sputum, blood, lung, and secondary metastases; (3) by its clinical 
course, its abrupt onset with general symptoms, followed by local 
signs, toxaemia and typical ending, and its cyclical self-limited course. 

Bacteriology. — 1. The pneumococcus or Diplococcus pneumonia? 
(Plate IV.), was first recognized by Fraenkel (188-1) and Weichselbaum 
(1886), though it was seen earlier by Sternberg, Pasteur, Eberth, Koch, 
Talamon, Leyden, and Guenther. Fraenkel and Weichselbaum first 
demonstrated its frequency and importance, and the diplococcus bears 
their name. It is an elliptical, lanceolate, encapsulated diplococcus; 
it is easilv seen in cover slips, it readily stains by the Gram method, 
and presents many cultural variations. Its atrium in pneumonia is by 
way of the respiratory tract, although in sepsis (q. v.) it may enter 
the blood by other avenues. From the lung it may spread, chiefly 
through the bloodvessels (as it did in Fraenkel's case, where it was 
traced from a pneumonic focus through a thrombophlebitic pulmonary 
vein) to the blood and to other viscera. Weichselbaum believes that 
it mav extend by way of the lymphatics. It is found in dust, in saliva, 
jand in 30 per cent, of healthy noses and throats, though usually with 
attenuated virulence. Again, the organism is virulent, and experi- 
mental inoculation has produced pericarditis, endocarditis, and em- 
pvema. It has been found in the joints, the blood, the brain, the 
bone-marrow; in otitis media, endocarditis, peritonitis, cholangitis, 
and endometritis; in the urine and faeces; and it may pass from the 
mother to the foetus. It may be a terminal septic infection or may 
produce pneumococcus sepsis, as the typhoid bacillus produces typhoid 



PLATE IV. 




L. SCHMIDT. FEC. 



The Diploeoeeus Pneumoniae, Stained with Methylene Blue 
and Fuehsin as a Counterstain. Taken from the Sputum of 
a Case of Acute Croupous Pneumonia. (Simon.) 



PNEUMONIA 137 

bacillseinia. Until very recently it was thought that typhoid and 
pneumonia were local infections with general symptoms, and that the 
presence in the blood of their microbes was a serious and a true com- 
plication. The typhoid bacillus is found in the blood in 95 per cent, of 
typhoid cases, and Rosenow, of Chicago, has found the pneumococcus 
in the blood in about 93 per cent, of pneumonia patients (v. i.). Indeed 
Prochaska last year found the Fraenkel-Weichselbaum organism in all 
of fifty cases. The pneumococcus is probably the sole cause of typical 
pneumonia, but other microorganisms are sometimes found. 

2. The pneumobacillus (Friedlander, 1883) is 1/* long, one-third 
as wide as long, with a capsule; it is found sometimes in the healthy 
nose, is larger than the pneumococcus, and does not stain by Gram's 
method. It has distinct biological and cultural characters, but its 
relation to pneumonia is not established. It is probably a mixed 
infection only. 

3. Other bacteria, such as the typhoid, colon, diphtheria, proteus, 
influenza, plague, and pyogenic organisms, have been found. The 
existence of psittakosis pneumonia, supposed to be contracted from 
animals, is denied by Lichtenstern. 

Indirect Causes. — (a) Age. — Pneumonia may be seen even in the 
new-born. Predisposition to infection is great up to the sixth year, 
and then much less until the fifteenth year. After the fifteenth year 
its frequency increases after each decade. Over half the cases of pneu- 
monia occur between the twentieth and fortieth years, and over 80 
per cent, between the tenth and fiftieth years, (b) Sex. — Eighty per 
cent, of cases are males. The relation to trauma is still in doubt, 
though contusions seem an occasional accessory factor, (c) Cold. — 
Cold and wet are predisposing factors. Pneumonia prevails especially 
in February, March, and April, when the weather varies, when the 
temperature is low, when the moisture is great, and when the winds 
are high. Three-quarters of all cases of pneumonia occur in cold 
months. It is possible that dust disseminates the dried sputum. 
Negroes are infected more frequently than whites. Pneumonia is 
half again as frequent in the cities as it is in the country. In the 
winter of 1903-4, when 4,000 persons died of pneumonia in Chicago, 
the author knew of practitioners in many villages and towns not one 
hundred miles distant, who did not see a single case, (d) Individual 
predisposition is said to be a more important factor than in any other 
acute infection. Susceptibility to pneumonia is increased by debility, 
overwork, and alcoholism, though the disease also attacks the most 
robust individuals. 

Toxin. — The toxin is not isolated, though it is assumed that a pneu- 
motoxin exists and produces the toxsemic symptoms; when an anti- 
toxin develops, the crisis occurs. 

Immunity. — Immunity does not result from one attack; as in 
erysipelas, recurrence of the disease is likely (in 13 per cent., 33 per 
cent., even 50 per cent.) ; ten, sixteen, or even twenty-eight recurrences 
are known. Though immunity can be produced in animals, it rarely 



138 THE SPECIFIC INFECTIONS 

lasts longer than six months (JOemperer, Foa, TVaskbourne), and it 
is doubted whether the serum has antitoxic properties. It is thought 
to possess bactericidal qualities only. 

General Clinical Course. — After a very short incubation of a few 
hours to a day, the disease begins suddenly. In children it often 
begins with convulsions — in the young with vomiting, and in older sub- 
jects with a severe chill, which often occurs in apparently perfect 
health, during work or sleep. On the first day there is a sudden rise 
of temperature; the face becomes red, even livid; the eyes are injected; 
the pulse and respiration are accelerated; the patient lies character- 
istically flat in bed; there is much depression; thirst, headache, and 
a sudden, sharp pain in the side develop, accompanied by cough and 
increased respiration. On the second day. the cough, pain, headache, 
and respiration-rate, increase, with dilatation of the alae nasi; the ex- 
piration is short and grunting, and speaking is difficult: leukocytosis 
develops. The sputum appears, or, if already present, becomes 
bloody: and this, with the sudden fever, chill, pain, and increased 
breathing, practically establishes the diagnosis before signs of con- 
solidation appear, if pulmonary embolism can be excluded. On the 
second or third day there are evidences of lung consolidation, such as 
the crepitant rale, bronchial breathing, and tympany which is soon 
followed by dulness; high temperature develops (with slight morn- 
ing remissions); the skin becomes dry and red; there is increased 
pulse and respiration: herpes, anorexia, coated tongue, constipation, 
moderate delirium, febrile urine, and coughing attacks, develop. The 
coughing is frequent but short in duration, voids a viscid, red sputum, 
and causes catching respiration, pain, and broken sleep. The prog- 
nosis cannot be made from the symptoms up to this time, since the 
clinical course may be unfavorably modified (a) especially by collapse 
due to myocardial or vasomotor paralysis, or to embolism of the lung 
from right-heart dilatation; (b) by profound toxaemia; (c) by delirium 
tremens; or id) by death, though at this stage it is rare. In favorable 
cases, when rhe toxaemia is spent, the crisis occurs; this usually happens 
on the uneven days (the fifth, seventh, or ninth) with gradually de- 
creasing dulness and with disappearance of other local findings. A 
"critical'' fall of temperature, pulse, and respiration-rate, and relief 
of nervous symptoms, and sweating, result. Lysis is less frequent. As 
a general statement, the toxaemia is the dominant feature of pneu- 
monia, and the consolidation is decidedly secondary. Furthermore, 
the degree of toxaemia has no necessary or constant relation to the 
amount of consolidation, just as the toxaemia of typhoid does not de- 
pend on the presence or degree of the intestinal changes. 

Analysis of Individual Symptoms. — 1. Onset. — Prodromes occur 
in 25 per cent, of the cases >:Grisolle), mostly in men between thirty 
and forty years, and rarely last more than five days; anorexia, depres- 
sion, headache, bronchitis, backache, and low fever, may be noticed. 
In one of the author's cases a pneumococcus infection began in the 
throat, then invaded the larvnx, and onlv after three weeks invaded 



PNEUMONIA 



139 



the lung. The organism was obtained at post-mortem. In four 
cases, low fever and hsematemesis for five to seven days suggested 
tuberculosis. In the two coining to autopsy, no tuberculous foci were 
found. In 75 per cent., however, the onset of pneumonia is sudden. 
Chill, convulsions, vomiting, and fever, after a short incubation, 
usually mark the brusque onset. Repeated chilly sensations, occur- 
ring when the heart is weak, do not as accurately designate the onset 
as does an initial rigor. A chill is present in 75 per cent, of the cases, 
and in no other acute disease except malaria is the chill so severe and 
constant; it lasts from a quarter to half an hour. The onset is atypical 
in senile pneumonia, and also when it occurs in the course of other 
diseases, — e.g., delirium tremens, typhoid, variola, and psychoses, — 
and the chill, cough, dyspnoea, pain, and sputum, are often absent, so 
that the existence of pneumonia may not be suspected. 

2. Fever. — The usual course of the fever is, first, a very sudden 
rise, especially in menstruating women (von Jurgensen) ; the fever 







Fig. 13. 








Day 


1 


2 


3 


4 


5 


G 


7 


TEMP. 

1C5 
















104 




/I 


/ 




J 


/ 


VI 


103 




/ 


v> 




V 


V 




102 




y 












101 
















100 








|b 








99 


A 












c 




1 














98 

































Fever-curve of typical case of pneumonia: A, sudden rise; B, pseudocrisis; C, crisis. 

is then continuous, often with not more than 1° or 2° variation for a 
few days; in three quarters of the cases the maximum fever is between 
102° and 105°. It may then remit, which is of good prognostic import; 
remittent fever throughout the disease occurs in some cases. Re- 
crudescences occur when consolidation passes from one lobe to an- 
other. The fever is lower or even absent in the aged, in alcoholics, 
and in cases of secondary pneumonia. Fever produces a marked 
loss of weight (twenty to thirty pounds). The rise preceding the crisis 
(perturbatio critica) may be mistaken for an ante-mortem rise. In 



140 



THE SPECIFIC INFECTIONS 



both conditions there may be delirium, convulsions, chill, or irregular 
pulse. A pseudocrisis may deceive the uninitiated physician, when 
the fever resumes its original elevation. Crisis occurs in 60 to 80 per 
cent, of cases, usually on uneven days, as noted by Hippocrates, — the 
fifth, seventh, ninth, or eleventh days, — and usually between evening 
and early morning. It very rarely occurs on or before the third day. 
It marks the end of the toxaemia but not of the consolidation. This 



Days 1 



Fig. 14. 
3 4 5 6 



10 



TEMP. 

105 






















104 






II 
















103 


A 


/ 


il 




\ 


* 1 










10'2 


/ 


1/ 


VI 




A 


7 


\A 








101 


/ 


/ 




N 


V 


/ 


v\ 


Va 






100 




V 








i/ 




M 


A 1 


\ 


99 






I 


' 








I 


^ 


\ 






















V 

























Pneumonia; remittent (subcontinuous) fever. 

requires several days more. In six to ten hours the temperature falls 
to (or below) normal, accompanied by sleep, euphoria, lessened pulse 
and respiration, lateritious deposits, and reappearance of the chlorides 
in the more abundant, limpid urine, and " critical" sweating, or even 
diarrhoea. The fall may measure even 10° or 11° and the pulse may 
reach 30. The precritical elevation and the beginning of the crisis 

Fig. 15. 



March 
Days 28 1 2 3 4 5 


6 7 8 9 110 11 12 13114 15 116 17 18 1 19 20 21 22 23 24 25 2G 27 28 29 30 


104 


Jla — [_jl_^ 1 


.102 


^^t-/4/lft l tA-l-^-A- -+- - 




^W§ ffi SSi-K _, =E 


I £*kb£\ 


/- — f^^^-^^-\AfU^^d- 




dz EE : 



Pneumonia fever-curve: exceptionally protracted though uncomplicated fever. 

may be attended by alarming symptoms, such as weak, irregular pulse 
and collapse. Lysis occurs in 20 per cent, of the cases. It is likely to 
occur when the fever lasts more than ten days, but lingering fever 
may indicate progression in other lobes and such complications as 
empyema or endocarditis. Lysis may be (1) gradual and continuous, 
or (2) slow and remittent. 



PNEUMONIA 141 

3. Respiratory Findings. — (A). Pain. — Pain in the side is pleural, 
though sometimes muscular. Its presence in 90 per cent, of the cases 
makes it of diagnostic value, since it is the most frequent respiratory 
symptom. It appears early, is increased by coughing or motion, and 
is sharp and sometimes agonizing. It is usually well localized over the 
consolidated focus, but in 8 per cent, may be referred along the 
lower intercostal nerves to the abdomen, in children especially, and 
sometimes in adults. Appendicitis is thus simulated in 2 per cent. 
Sometimes the pain is located over the gall-bladder, or on the 
opposite side of the chest. Pain is absent in central, secondary, or 
upper-lobe pneumonias; in the aged, and often in children; and in 
cases with great delirium. 

(B). Dyspncea. — Dyspnoea is frequent; it is caused by pain and 
especially toxaemia, but also by temperature, cyanosis, diminished 
respiratory area, bronchitis, and complicating pulmonary oedema, and 
scoliosis. 

(0). The Respiration-rate. — The respiration-rate is practically 
always increased to 24 or 40, (or more in children) ; and in two-thirds 
of all cases, it ranges between 30 and 50; it almost never rises to 60 
or 80 except in the death agony, but such frequency is common in 
miliary tuberculosis. The author once saw a rate of 96 with recovery; 
the pulse was 90. Dilatation of the nares is said to be ominous, but 
seems to the author common in ordinary cases. Alteration of the pulse 
and respiration ratio was first noted by von Jurgensen; the normal 
ratio of 1 to 4 or 4.5 becomes 1 to 3 or 2. On very rare occasions the 
respiration-rate may be normal. Thus, in one instance with the entire 
right lung consolidated, respiration was 18 (without medication). 

(D). The Cough. — The cough always irritates, is sometimes dan- 
gerous, and seldom relieves the patient. It is usually present from the 
beginning of the disease to the crisis, and almost invariably occurs 
in lower-lobe pneumonia, but is often absent in upper-lobe consoli- 
dation, in terminal or secondary pneumonia, in cases where there 
is much delirium, in the aged, and the young. It is sometimes 
pleuritic. 

(E). The Sputum. — The sputum is at first transparent, mucous, and 
very scanty. It soon becomes viscid, and is difficult to raise, and to 
expectorate, as it adheres to the mouth and lips. It is so viscid that 
the sputum-cup may be inverted without any flow of the sputum. In 
two days it becomes red, and rusty (80 per cent, of cases). Later, the 
sputum becomes more abundant, averaging between one and seven 
ounces daily, but is rarely very abundant or fluid. Increased fluidity 
may result from weak heart, or decreased coagulability of the blood. 
Rusty sputum is often absent in children who swallow their sputum; 
in cases of upper-lobe consolidation, in which there is less hemorrhage, 
less consolidation, and less cough to dislodge exudation; and, finally, 
it is often absent in the senile and secondary pneumonias, possibly 
because of very early gray hepatization. The cause of unusual color 
in the sputum, such as lemon- or brick-color, is unknown ; it is some- 



142 THE SPECIFIC INFECTIONS 

times observed in pulmonary oedema, or in incipient gangrene, and 
renders the prognosis uncertain. Safranin color (sputum croceum) 
indicates resolution. The rusty sputum is of great diagnostic value, — - 
e. g., in the beginning of the disease or in central pneumonia — and 
generally is of good import. Fibrin threads (or "casts") of the bron- 
chioles are usually seen between the third and seventh days. On 
shaking the sputum in water and catching the shreds on a slide they 
appear clubbed at their alveolar ends. They are almost, but not 
wholly, pathognomonic, since Laennec found them in tuberculosis, 
and in fibrinous bronchitis. They consist of fibrin, white cells, fatty 
cells, and epithelium. Thinner casts, analogous to the cylindroids 
of the urine, and spirals, are sometimes found. The sputum is rich 
in chlorides, especially in calcium chloride. Microscopically the spu- 
tum contains blood cells, various epithelia, the pneumococci (found 

Fig. 16. 












, 







1 



Fibrinous coagulum from a case of croupous pneumonia. (Bizzozero.) 

first by Wolff in sputum and by Weichselbaum in the lung), and often 
streptococci. 

(F). Lung Pathology. — The lung pathology was developed in 
1819, by Laennec, who was the first to accurately separate pneu- 
monia from pleurisy. He described three stages. (1) The stage of 
hyperemia is very exceptionally observed unless the subject dies in 
twenty-four to thirty-six hours, because hepatization (v. i.) develops 
rapidly; hyperemia is most often seen at the edges of the consoli- 
dated lung where the pneumonia is beginning to extend. The lung 
crepitates and floats, though less than normal; it is red, voluminous, 



PNEUMONIA 143 

and tears readily, — [i.e., it has lost its elasticity], and exudes a sero- 
sanguineous fluid on section. Under the microscope, congestion, serum, 
and diplococci in the alveoli, are observed. The alveolar epithelial 
cells swell and desquamate, which, according to some observers, are 
the primary changes. (2) In the stage of red hepatization, the lung is 
evenly red, friable, airless (not wholly so in pneumonia of an upper 
lobe), and sinks when put into water. Its weight is increased ten to 
fifty ounces. The lung is enlarged to the size of deepest inspiration 
(Rokitansky, who developed the gross anatomy of pneumonia), and 
has marks of the ribs on its fibrin-coated surface. On scraping the 
cut surface, fibrinous casts or plugs of the bronchioles are observed. 
The lung is granular on section (Laennec), which results from exuda- 
tion into the alveoli. These granulations are smaller in the young 
and are larger in patients with emphysema. They are seen best with 
oblique illumination. Under the microscope, coagulated blood and 
exudate, alveolar epithelium, injected bloodvessels, emigration of 
leukocytes, diplococci, and meshes of fibrin, are noted. (3) In the 
stage of gray hepatization, the granulations are grayish-yellow, and are 
not red because the blood is absorbed; they are larger and looser 
than in the second stage. The connective tissue is grayer than the 
granulations, and is sharply defined by the lung pigment. It has been 
claimed that death always occurs if this stage is reached. If the 
patient lives, the granulations disappear; the lung exudate becomes 
semi-fluid (purulent infiltration); the pus can be washed out; there 
is a fatty emulsion, and resorption occurs by the lymphatic vessels 
and not by evacuation through the sputum. Enzymes (ferments) dis- 
solve the exudate; the products of this autolysis are excreted by the 
kidneys. 

Seat of pneumonia: The lobar process begins at the hilum and 
extends to the pleura, which is usually inflamed. If it remains at the 
hilum it is called central pneumonia (1.7 per cent.); if the entire lung 
is involved, it is termed pneumonia totalis or massiva; the terms 
"double pneumonia" and " crossed pneumonia" are self-explanatory. 
The lobes are involved in the following order of frequency: (1) 
Right lower lobe; (2) left lower; (3) right middle; (4) right upper; 
(5) left upper lobe. Jurgensen's collation of 16,614 cases of pneu- 
monia shows that the right lung is affected in 53 per cent., the left in 
37 per cent., and both lungs in 10 per cent. Fraenkel found the 
upper lobes involved in 16 per cent, and the lower in 84 per cent. 

(G). Physical Signs. — The physical signs develop in the lungs only 
after twelve to twenty-four hours, or later. 

I. Inspection. — The decubitus is variable. It is dorsal in lower- 
lobe, and erect in upper-lobe pneumonia; the patient at first lies on 
the sound side to avoid pain; on the diseased side later, for better 
expansion of the sound lung. The spinal column is concave toward 
the diseased lung for its better immobilization. The excursion is less 
on the diseased side because of pain. Litten's diaphragmatic sign is 
absent and the sound lung is vicariously active. The diseased side 



144 THE SPECIFIC INFECTIONS 

is larger by one-half to one inch. The accessory muscles of respira- 
tion are active and dilatation of the nares is seen. Systolic pulsation 
of the lung occurs when the lingual lobe is consolidated, or, in the 
first stage, when the heart beats against semifluid exudation [Graves 

II. Palpation. — This detects the lessened excursion more readily 
than does inspection; vocal fremitus is usually increased because of 
better sound propagation, fremitus being normally greater on the 
right than on the left side. It is decreased (1) by occlusion of the 
bronchus by fibrinous plugs, which are, however, usually dislodged by 
having the patient cough; ^ by coincident pleural effusion: [3] by 
great consolidation {Gerhardt/, in which the chest wall becomes tense. 
It is claimed that the consolidated side is the warmer. Pleural fric- 
tion may be felt. 

III. Percussion. — [1) A tympanitic note is obtained in the first 
stage (Skoda's resonance). This is caused by decreased elasticity of 
the lung and therefore decreased tension and amplitude of vibration, 
which is due to the swelling of the alveolar epithelium and turgescent 
capillaries. This condition may last as long as two days, and causes 
doubt as to the side involved, especially when pain is bilateral and 
breathing indeterminate (whence the value of crepitant rales). Tym- 
pany in the later stages is not uncommon in upper-lobe pneumonia 
where exudation is usually incomplete. It is rare in lower-lobe pneu- 
monias but may occur over an upper lobe in total pneumonia from the 
air in the bronchus. It may be attributed to the stomach (Finckler in 
cases of left lower-lobe pneumonia: to some moderate compression, 
— e. g., of right upper lobe when right middle and lower are con- 
solidated: to the normal lung lying over deeper consolidation or to 
resolution. Tympany may remain days or weeks after the crisis. 
Careful watching of the tympany, during the acute stage, often leads 
to detection of extension, which is shown by relaxation of the lung 
tissue, contiguous to areas already consolidated. 2) Dulness is 
usually found on the second day. It is the percussion sign of the 
second stage. When complete, it corresponds to the lobe confines, 
which are outlined in Fig. 33 under article, Pleurisy. The dulness 
is not absolute. It is usually first detected in the posterior axillary 
line in lower-lobe pneumonia and generally is more complete behind 
than in the front of the chest and more in a lower- than in an upper- 
lobe involvement. Dulness is difficult to detect if the area is not at 
least 1 by 2 inches, or if it is deeper than 2 inches from the surface. 
It is absent in central pneumonia. It disappears with resolution. 
Wintrich's palpatory percussion is most valuable. TVmtricrrs change 
of pitch 'on opening the nioutlT is heard in upper-lobe pneumonia, 
where the percussion wave is conveyed to the bronchus more often 
than in lower pneumonia. Cracked-pot resonance over the edge of 
the consolidation bordering on sound tissue is due to irregular tension. 

IV. Auscultation. — Decreased breathing is often noticed at first 
(Grisolle). Stokes diagnosticated the first stage by sudden local 
puerile breathing with fever and by disordered breathing. 



PNEUMONIA 145 

First Stage. — The crepitant rale of Laennec remains the auscultatory 
sign of the first stage; but, as Laennec stated, it is not absolutely spe- 
cific, because it occurs also in tuberculosis, oedema, infarct, hypostasis, 
and bronchiolitis. It probably has its origin in the viscid exudate 
in the finest tubules and in the alveoli. Some consider it pleural. It 
is coarser in the aged and in children because the large tubes are 
more involved. It is heard at the height of inspiration as a succes- 
sion or shower of delicate crackles. When not heard, a coughing 
effort may elicit the crepitant rale. It often disappears after a num- 
ber of deep inspirations; e.g., when it is demonstrated to a class, 
only the first students hear it. Dislodged plugs may occasion expira- 
tory rales. The crepitant rale disappears during the second, and 
reappears in the third stage. 

Second Stage. — The distinct, intense bronchial breathing is due to 
better transmission of the bronchial sounds through the solidified 
lung. It sounds as though nothing intervened between the lung and 
the stethoscope and it is especially clear and near when the ear is 
placed directly on the chest. It is absent or partial in central pneu- 
monia, especially anteriorly, in coincident pleurisy, and in obstruction 
of the bronchi by mucous or fibrinous casts. In the latter case, several 
coughs usually loosen the obstruction and restore the bronchial breath- 
ing. Bronchophony, due to the voice sounds being better transmitted 
through the consolidated area, is heard when the patient counts or 
speaks, but especially after each involuntary expiratory grunt. JEgoph- 
ony is occasionally heard, as well as Baccelli's phenomenon (auscul- 
tatory whispering). The crepitant rale disappears in this stage, 
except at the edges of the hepatization where extension may be 
taking place. 

Third Stage. — The crepitant rale reappears and is then known as 
the rale redux. 

4. Circulation. — (a) The pulse rate is usullay 100 to 120; in 
children it may rise to 200. It is also rapid in the aged, and in cases 
with severe toxaemia. In adults, a rate of 130 to 140 makes the prognosis 
less favorable. If the rate is slow at the height of the disease the prog- 
nosis is grave, for heart or brain complications are indicated (Traube). 
Irregularity and gallop-rhythm (one systolic tone and two diastolic 
tones) are of poor prognostic import. Antecritical irregularity fre- 
quently occurs. The pulse is usually deceptive, because its fulness 
is of no value in prognosis. It is not often dicrotic. Extensive pneu- 
monias may compress the subclavian artery, making the pulse smaller 
in one wrist than in the other. In the right heart, dilatation from 
toxaemia may occur; the second pulmonic tone is accentuated but 
this is not observed when the right heart becomes greatly weakened. 
There are functional bruits especially in children. In very rapid 
cardiac action, the two heart tones sound alike, resembling the foetal 
heart tones (embryocardia). (b) Collapse is usually due to myo- 
cardial or to central vasomotor paralysis and may occur at the onset. 
acme, defervescence, or convalescence, (c) The blood shows anaemia, 

10 



146 THE SPECIFIC INFECTIONS 

and Bollinger suggests that the oligemia, resulting from large exudates, 
may explain some cases of collapse. The fibrin increase is readily- 
noted in fresh blood preparations. A polymorphonuclear leukocytosis 
of 15,000 to 30,000 (or even 100,000) appears early, and lasts slightly 
longer than the fever. In Cabot's counts, the leukocytes ran between 
15,000 and 30,000 in 75 per cent, of his cases. The eosinophiles are 
decreased or wholly absent until the affection reaches its height, 
whence the favorable significance of their reappearance. The lymph- 
ocytes are decreased. During convalescence many myelocytes appear. 
The white count remains high in delayed resolution or with complica- 
tions. A low count is generally unfavorable. Pneumohcemia (pneumo- 
cocci in the blood) was, until recently, considered of bad prognostci 
import and it was once stated that but 15 per cent, of cases of pneumo- 
haemia recover, but now it is not considered of great prognostic value. 
Rosenow found pneumococci in blood cultures in 93 per cent., and in 
smears in 42 per cent. They were most abundant on the fourth or 
fifth days, and few in number before or at the crisis. In making 
cultures, half a dram of blood is taken and mixed with 98 or 99 parts 
of bouillon. Prochaska found pneumococci in 100 per cent., when two 
or three drams (10 c.c.) of blood were taken for cultivation; they are 
probably present in all cases, though some think that they appear only 
when the protective resistance of the tissues is lost and death is immi- 
nent; pneumohsemia has been found before hepatization. Rosenow 
noted increased agglutinative power of the serum until the crisis occurs. 

5. The Digestive System. — There is the febrile tongue, thirst, and 
anorexia. Vomiting results from cerebral toxaemia (especially in chil- 
dren), vagus irritation, coughing, or alcoholic pharyngitis. The dis- 
tressing, sometimes dangerous, tympany and the occasional diarrhoea 
are usually toxsemic. Constipation is the rule. There is often some 
intumescence of the liver. Fraenkel found splenic tumor in 15 per 
cent, of all cases and in 40 per cent, of fatal cases. 

6. The Skin. — The red cheek on the affected side was known to 
Aretseus. The skin is usually dry, but miliaria and sweating may be 
seen, especially in children. Herpes is found more often than in any 
other disease (30 to 50 per cent.) It appears from the third to fifth 
day or later, chiefly on the lips, nose, mouth, cheek, ear, or rarely on 
the anus or genitalia; Howard found causal changes in the Gas- 
serian ganglion. Herpes is of diagnostic value, e. g., from typhoid, and 
is generally of favorable import. Rarer eruptions are erythema, rose- 
olas, urticaria, purpura, or pemphigus. The lymph-glands are enlarged 
in 25 per cent, of the cases. 

7. The Urine. — Characteristic fever urine is found, and the urea 
is increased threefold, especially after the crisis from over production 
and accumulation during the fever and from the resolving exudate. 
The uric acid, ammonium, and creatin, are increased. The chlorides 
are decreased from 225 grains daily to 30 grains, or they may be absent 
until the crisis or two days later, when they reappear in increased 
quantities (first observed by Rottenbacher) ; no satisfactory explana- 



PNEUMONIA 147 

tion for the decrease of the chlorides is known. The sulphates and 
phosphates are decreased. Pick notes that the urine often becomes 
neutral or alkaline after twenty-four to forty-eight hours; this is due 
to sodium deposit in the lungs, which condition lasts from twenty-four 
to thirty-six hours. Albuminuria and cylindruria appear in about 50 
per cent, of the cases; peptonuria and acetonuria are not uncommon, 
and the diazo reaction appears in 20 per cent. Hematuria is found 
in 1.6 per cent. Nephritis seldom occurs (1 to 2 per cent.), and uraemia 
is very uncommon. Pneumococci have been found in the urine and 
in the glomeruli (Koch, Nauwerck). 

8. The Nervous System. — Headache is almost constant. There 
may be insomnia, restlessness, or sopor, and the latter is always omi- 
nous. Delirium (22 per cent.) occurs in adults, especially in cases of 
upper-lobe pneumonia, alcoholism, or marked toxaemia. Delirium 
and other nervous symptoms resulting from exhaustion may occur 
at, or even for a week after, the crisis. Venesection in former times 
greatly increased the percentage of delirium. The patellar reflexes 
are often absent and the pupils may be dilated or sluggish. Con- 
vulsions, coma, and rigid neck, in children, result from toxaemia of 
the more sensitive young brain, from complicating otitis, from brain 
oedema, or from actual meningitis. Hemiplegia may result from (1) 
brain oedema or anaemia, or (2) arteriosclerosis and weakened heart. 

Mechanism of Death in Pneumonia. — Death is rare in the first 
two days. If it occurs within this time, its cause is usually some 
antecedent malady such as nephritis or typhoid. (1) Toxaemia is 
all-important in its action on the heart, brain, and vasomotor nerves. 
Death results with a rapid pulse, rapid respirations, algid extremities, 
and obtunded sensorium. (2) The extent of pneumonia is the least 
important factor. A massive pneumonia in a robust person causes 
less disturbance than a very small patch in a nephritic patient. There 
is no parallelism between the area hepatized and the resulting toxaemia. 

(3) Pulmonary oedema is either mechanical (cardiac) or inflamma- 
tory — i. e., the first stages of an incompletely developed pneumonia. 

(4) Pneumococci in other tissues, e. g., pneumococcic meningitis, endo- 
carditis, and pericarditis. 

Complications. — These are fortunately few as compared with those 
of typhoid but they are severe. 

1. Pleurisy. — Pleurisy is so constant that the name of pleuro- 
pneumonia is rather justified, the pleura being covered with a very 
thick, tenacious, curdy exudate. It is usually due to the pneumo- 
coccus; if due to the streptococcus, it is a complication of great dan- 
ger. Effusive pleurisy is said to occur in 5 to 15 per cent., though 
Fraenkel saw serofibrinous pleurisy in but 1 per cent, in 1,000 cases. 
Pleuritis is para- or metapneumonic, serofibrinous (5 per cent.) or 
purulent (2 per cent.), febrile or afebrile. The presence of leukocytosis 
in a pleurisy may indicate a previous unobserved or overlooked pneu- 
monia. Pneumonia may exist on one side and pleurisy on the other, 
— e. g., an upper-lobe pneumonia with contralateral pleurisy (Traube). 



148 THE SPECIFIC IXFECTIOXS 

The author has seen two such cases. The prognosis is not necessarily 
unfavorable, even when operation for pneuniococcic empyema is re- 
fused. Interlobular empyema is most serious, because it so often 
escapes detection. Pneuniococcic empyema occurs in 2 per cent, of 
cases of pneumonia and is notable since the pneumococcus so seldom 
provokes suppuration in the lung. Its symptoms are discussed under 
pleurisy. 

2. Endocarditis. — Acute endocarditis complicates pneumonia in 
1 per cent. (Chvostek) of all cases and in about 5 per cent, of fatal 
cases, though higher figures are given, 14 per cent. (Kanthack) and 
16 per cent. (Osier); all autopsy figures are usually higher than figures 
in general practice. The pneumococcus is found in the vegetations. 
The valvular exudate is voluminous, though ulceration, valvular aneu- 
rysm and perforation are less common than in staphylo- and strepto- 
coccic forms. Endocarditis develops especially on old valvular lesions 
in the left heart and most frequently on the aortic valves (Xetter, 
Heschl). The right heart is involved three or four times as frequently 
as in endocarditis due to other bacteria. Sixty per cent, of cases are 
associated with meningitis. Middle-aged adults are more often 
affected than the young, and women more often than men. Symptoms 
may be absent. Endocarditis is probable when a murmur, systolic or 
particularly diastolic, occurs with irregular and protracted fever, chills, 
sweats and embolism (50 per cent.). Symptoms may directly follow 
the pneumonia or develop after one-half to one week of normal tem- 
perature. The endocarditis is malignant in 80 percent, of cases; in 
the balance, milder endocarditis occurs; 2b per cent, of cases of ulcer- 
ative endocarditis are pneumococcic. Fever is sometimes, and leuko- 
cytosis frequently, absent. {Vide chapters on Ulcerative Endo- 
carditis and Septicopyemia.) 

3. Pericarditis. — This is dangerous though not necessarily fatal. 
Some figures place its post-mortem frequency at 5 to 15 per cent, 
but Fraenkel estimates it at seven-tenths of 1 per cent. About 60 per 
cent, of cases are latent because the pericardial rub is frequently 
absent. Pericarditis occurs more often in children than in adults and, 
in all cases, chiefly at the height of the disease. Effusive pericarditis 
is less common than the fibrinous form. It is more common when 
the left lung is involved. 

4. Arteritis and thrombophlebitis are far less frequent than in 
typhoid, but nearly every clinician encounters a few cases. Steiner 
collected forty-eight cases of venous thrombosis (1903); it most often 
develops in convalescence and usually (75 per cent.) heals, though 
early embolism or permanent venous obstruction may develop. 

5. Nervous Complications. — The chief nervous complications are 
delirium tremens, meningitis, or, less frequently, Landry's ascending 
paralysis, cerebral thrombosis, embolism, encephalitis, and neuritis. 
Meningitis, first observed by Immermann and Heller, varies in fre- 
quency with the epidemic; it occurs in 5 per cent, of autopsies, and 
in three-tenths of 1 per cent, of all clinical cases. It occurs in asthenic 



PNEUMONIA 149 

patients, in upper-lobe pneumonia, and is often accompanied by 
endocarditis. Symptoms are often wholly lacking. One of the author's 
cases died at the dinner-table a week after apparently complete con- 
valescence, and the autopsy showed a quarter inch of pus over the 
convexity. The usual meningitic symptoms develop if infection 
reaches the base of the brain. This, however, is not usual. Lumbar 
puncture may determine the diagnosis, which is more easily made if 
meningitis occurs in convalescence. The prognosis is considered ab- 
solutely unfavorable, yet Achard and the author have each seen recov- 
ery in cases which were proven bacteriologically by lumbar puncture. 

6. Alimentary Complications. — These are few. Croupous gastritis 
and enteritis, parotitis or peritonitis (q. v.), are not frequent. Dieu- 
lafoy described a hemorrhagic ulcerative gastritis, caused by pneumo- 
coccic embolism and attended by gastrorrhagia. Icterus is frequent 
in some epidemics. Its average frequency is about 1 per cent., though 
Chvostek saw it in 21 per cent, of his cases. Its causes are variable; 
(a) lessened excursion of the diaphragm in right lower-lobe pneu- 
monia; (6) hepatic stasis; (c) duodenal catarrh; (d) hematogenous 
jaundice resulting from absorption of the hemorrhagic exudate in the 
lung or toxsemic solution of the red blood-cells (haemolysis). Pneu- 
mococcic involvement of the peritoneum will be described under 
Peritonitis. 

7. Lung Complications. — Suppurative mediastinitis was first ob- 
served by Weichselbaum, who regards it as the connecting link between 
pneumonia, meningitis, and pericarditis. Pulmonary induration 
(cirrhosis of the lung) may follow incomplete resolution, especially 
after repeated attacks of pneumonia (Charcot); it is usually febrile. 
Abscess is not frequent (5 per cent., Laennec, or once in 1,200 cases, 
Fraenkel). Skoda emphasized the uncertainty of its signs and the 
difficulty in its diagnosis, for pus and elastic fibers in the sputum, 
and less frequently cholesterin and hsematoidin crystals may be the 
sole sign, and continual coughing may be the chief symptom. Sup- 
puration may result from the pneumococcus or from the pyogenic 
bacteria proper. Gangrene occurs in 1 to 2 per cent, of the cases. 
Clinically it is recognized by the horribly fetid sputum. Abscess 
and gangrene are more fully treated under Diseases of the Lungs. 

8. Complications in the Joints. — Genuine rheumatism may occur 
with, before, or after a pneumonia. Sixty-eight cases of pneumococcic 
arthritis (pseudorheumatism) were reported by Slaughter (1903). 
The arthritis may be serous or purulent. The knee is affected in 30 
per cent. Arthritis is monarticular in 62 per cent, and fatal in 65 per 
cent, of the cases (Herrick). Fraenkel found the pneumococcus con- 
stantly in the bone-marrow. 

Clinical Types and Variations. — These are as follows : 

1. Abortive Pneumonia. — This type is recognized by the rusty spu- 
tum, fever and respiratory disturbance, but produces no hepatization. 

2. Ephemeral Pneumonia. — This type is characterized by one day 
of fever, and very rapid resolution. 



150 THE SPECIFIC INFECTIONS 

3. Relapsing Type. — One attack occurs with fall of temperature, 
and then the entire cycle recurs. It occurs in 0.3 per cent. (Wagner). 
The recurrent type {v. s. Immunity). 

4. Local Variations. — Apex pneumonia is often more severe and more 
atypical in symptoms and signs ; it is frequently adynamic, and pulmon- 
ary and cerebral complications are rather more common. Migratory 
pneumonia travels from one part to another (the so-called erysipelas- 
pneumonia). Central and massive pneumonia (pneumonia totalis, 
affecting an entire side) will be considered under diagnosis. 

5. In Children. — An abrupt onset occurs without chill (before the 
seventh year) but with vomiting (50 per cent.) or convulsions (7 per 
cent.) and other cerebral or meningeal symptoms. Cough is often 
absent, no sputum appears, and the pain (third to fifth year) is referred 
to the abdomen but without tenderness there. Pain is a more impor- 
tant symptom than increased respiration, which occurs with any ele- 
vation of temperature. The respirations may number eighty in cases 
under two years of age; in older children, fifty. Crepitant rales are 
usually absent because of the superficial breathing caused by pain. 
Latency of physical signs, such as absence of bronchial breathing, 
bronchophony, or dulness, is sometimes noted. Localization is more 
often central, apical, or migratory. The fever may rise more slowly 
and lysis is more frequent than in adults. Riviere found croupous 
pneumonia as frequently (or more frequently) in children under two 
years as in those above two years. In 118 cases reported by Morse, 
50 of them occurred in the first, and 68 in the second year of life. 

6. In the Aged. — Pneumonia is frequently latent, insidious, and 
asthenic, with ill-marked signs, without chill, even without fever, 
and often without cough, pain, or sputum. 

7. In Alcoholics. — The same latency or lack of type may be noted. 
In alcoholics the clinical picture of delirium tremens masks the lung 
lesion. , 

8. Asthenic Pneumonia. — In asthenic " typhoid," "biliary," or 
"toxic" pneumonia, toxaemia is dominant, there are high fever, en- 
larged spleen, albuminuria, often icterus, mixed infections, severe 
complications, such as meningitis or gangrene, and high mortality. 
These asthenic cases contrast strongly with what we might call " walking 
pneumonia." The author has had two patients who worked through- 
out the clinical course. 

9. Pneumonia Secondary to Other Diseases. — Pneumonia may be 
secondary to tuberculosis, emphysema, arteriosclerosis, hepatic cir- 
rhosis, nephritis, diabetes, typhoid, influenza, diphtheria, and plague. 
Anaesthesia by ether is thought to predispose toward pneumonia by 
irritation of the respiratory tract. The nose and mouth should be 
cleansed before anesthetization to remove native germs. The fre- 
quency of ether pneumonia in abdominal operations suggests the 
possibility of embolism as a factor. 

Various microorganisms are found — colon bacillus, streptococcus, 
etc. The physician may often fail to recognize this type because 



PNEUMONIA 151 

it is atypical, ill developed, or masked by the primary disease. 
Pathologically, the hepatization is rarely typical and is more lobular 
than lobar; the lung section is smooth and moist, and the exudation 
is more cellular than fibrinous. 

10. Delayed or Imperfect Resolution. — Normal resolution is chiefly 
effected by lymphatic absorption, for the sputum voids but little of 
the exudate, (a) Slow resolution may require several weeks or even 
months, especially in apical involvement, and is more often seen 
after lysis than crisis. The toxaemia disappears but dulness and 
bronchial breathing persist. (6) Imperfect clearing up of the lung 
may be caused by abscess formation, old pleuritic adhesions, fresh 
pericarditis, or inflammatory involvement of the connective tissue 
and lymphatic vessels. Induration of the lung by organization of 
the exudate is usually febrile (Fraenkel). (c) The so-called pneu- 
monia migrans is a pneumonia which slowly progresses from one part 
to another. 

Diagnosis. — Mistakes are rare in the diagnosis of primary, frank 
pneumonia in adults — they occur mostly in cases of aged individuals, 
of alcoholics, of children, and in cases of pneumonia secondary to 
cancer, nephritis, diabetes, etc. Therefore, all cases with chronic 
disease must be closely examined when the respiration, pulse, and 
temperature rise, or when, even without these or other symptoms, the 
subject of chronic disease is not doing well. 

1. Onset Symptoms. — The chill in adults, convulsions in children, 
which occur also in such other diseases as nephritis, infantile palsy, 
and alimentary catarrh, vomiting in the very young or in adolescents, 
suggest the possible onset of lobar pneumonia. Chill, pain in the 
side, sudden high fever, and rusty sputum, are almost sure symptoms, 
because pneumonia is practically the only disease in which they occur. 
Care must be taken to avoid the chief diagnostic confusion — infarct 
of the lung — in which the same symptoms may obtain, but in which 
the sputum is reddish, is not viscid, is usually darker, and far more 
abundant than in pneumonia. In 25 per cent, of cases the onset of 
pneumonia is not typically brusque, but the physical findings of pneu- 
monia are present without a history suggestive of the disease ; indeed 
it may rather be suggestive of simple pleurisy, grippe, etc. The pro- 
fession regards pneumonia as a disease with a severe onset, but the 
laity, and with reason, emphasize the importance of antecedent ex- 
posure, colds, or bronchitis. The prodromes of pneumonia are too 
often disregarded by physicians, even when they carefully exclude 
pneumonia which is strictly secondary to other acute or chronic dis- 
ease. In a very appreciable percentage of cases the prodromata are 
not brief and may last longer than two or three days, or even a week. 

2. Diagnosis from the Physical Findings. — The physical findings are 
usually detected in the typical case upon thorough examination, and 
as a rule usually appear within two days after the characteristic symp- 
toms of onset. They are the well known lessened expansion on the 
side of the lesion; increased vocal fremitus; distinct dulness; bron- 



152 THE SPECIFIC INFECTIONS 

chial breathing; the crepitant rale; the grunting, abbreviated, ex- 
piratory "huh" sound, and a bronchial tone to the whispered or 
louder voice sounds. Typical as are these simple findings in their 
usual grouping, and easily recognized as they are when the student 
or practitioner has once heard and learned them, nevertheless many 
conditions modify their classical appearance and character. Thus, 
the fremitus is decreased in massive consolidations which render tense 
the chest wall, in coincident pleural effusions or in fibrinous plugging 
of the bronchi. The latter may, however, usually be dislodged by 
repeated coughing. The dulness is found only in hepatization which 
is nearly complete and is both preceded and followed by a tympanitic 
note. The crepitant rale is found only in the first and third stages, 
but in almost every case can be found in some part of the affected 
lung. Bronchial breathing is rudimentary or absent in incomplete 
hepatization, is often so in upper-lobe pneumonias, in complicating 
effusive pleurisy, and in obstructed bronchi. These physical symp- 
toms are pathognomonic only in connection with the cyclic course 
of the disease, the symptoms of onset, the disturbed pulse and respi- 
ration ratio, the pneumohsemia, diminished chlorides, herpes, leuko- 
cytosis and crisis. 

3. Localization. — Massive pneumonia (total pneumonia of one 
side) not infrequently simulates pleurisy, because fibrinous plugging 
of the bronchi is not uncommon, and prevents bronchial breathing, 
bronchophony, and the crepitant rale; and again, the fremitus may 
be absent together with some slight, although rarely essential, luxa- 
tion of neighboring viscera. Consideration of the onset, the later 
cyclic course, and the dislodging of the plugs by forcible coughing, 
almost invariably determine the diagnosis. Too much is generally 
said about central pneumonia. Such cases exist beyond doubt, 
but considerable conservatism is necessary in their diagnosis. All 
pneumonias are central in their incipiency but rarely remain 
so. The author lately demonstrated a case in clinic in which 
everything pointed to pneumonia, but the local findings did not ap- 
pear for a week, although they were carefully searched for twice 
a day. 

4. In Children. — Pneumonia in children may be mistaken for 
abdominal disease, for pleurisy, or for brain affections. The "cere- 
bral pneumonia" of Rilliet and Barthez may be (a) convulsive, occur- 
ring under two years, with fever, vomiting, and convulsions; but the 
evenly high fever is very suggestive even if the cough and dyspnoea 
are obscured by the brain symptoms; or (b) meningeal, occurring 
between the second and sixth years; but the pulse is not slow, and 
there is no deep breathing, nor change of color in the cheeks, as is 
observed in meningitis. 

5. Differentiation from Pleurisy. — The differentiation is usually easy, 
but confusion is unfortunately common. 

The history may be suggestive but it can be indefinite, especially in 
hospital cases. 



PNEUMONIA 



153 



Pneumonia- 



■vs.- 



-Pleuritic Effusion. 



Onset sudden, with chill, vomiting, Gradual; chilly sensations rather than 
herpes. rigor. 

Friction less common; may be present. Usually, at some time in the clinical 

course. 



Cyclical short course; high fever, crisis. 

Sputum rusty. 
Leukocytosis. 

Ectasia absent. 

Fremitus increased (coughing usually 
dislodging bronchial plugs). 



Dulness, preceded and succeeded by 
tympany (tympany or partial dul- 
ness in upper-lobe pneumonia is 
not uncommon). 



Crepitant rales, bronchial breathing (un- 
less bronchus is plugged), and bron- 
chophony. 



No essential luxation of heart, liver or 
spleen (except the slightest in pneu- 
monia massiva). 



Paracentesis negative. 



Longer duration, lower fever, lysis. 
Often tuberculous foci at apex, etc. 

Mucous, if any. 

Usually absent, unless purulent or com- 
plicating a pneumonia. 

Present. 

Absent over effusion unless irregular 
adhesions bind the lung in places to 
the chest wall; increased above over- 
compressed lung or in the inter- 
scapular region. 

Flatness, increased downward; enter- 
ing Traube's space on the left side, 
unless adhesions forbid. Level may 
occasionally shift with change of 
position. (See Fig. 33 under Pleu- 
risy). 

Decreased or absent respiratory murmur; 
we may have bronchial breathing in 
interscapular region from compres- 
sion, or even through the fluid, both 
in adults and children; segophony. 

Luxation of viscera named, is usual but 
not invariable, even in large effusions. 



Tapping nearly always decides doubtful 
cases; fluid is found over the flat area. 



In lung tumors, bronchial breathing, bronchophony, dulness, red 
(or green) sputum, are also noted, but the history suffices for differen- 
tiation. In acute tuberculous infiltration, the course differentiates it 
from upper-lobe pneumonia by the gradual onset, in which cough 
sputum, and typical physical findings are absent. Many mistakes 
in both directions are made, simply by forgetting that pneumonia 
may occur in the apices, in which the incomplete exudation may im- 
part a tympanitic note, and that the breath sounds are not always 
typically bronchial, at least anteriorly. In some cases tuberculous 
pneumonia may commence like lobar pneumonia (see Acute 
Pneumonic Form, under Course of Pulmonary Tuberculosis). 

Prognosis. — Pneumonia is the most fatal acute disease and even 
has a greater death-rate than tuberculosis. In 1903, 4,629 persons 
died of pneumonia, in Chicago, and, in 1904, 8,360 died of it in New 
York City. From 1851 to 1890, the mortality, in Chicago, from tuber- 



154 THE SPECIFIC INFECTIONS 

culosis, was 35 per cent, more than from pneumonia. From 1891 to 
1901, the pneumonia death-rate was 9 per cent, more than the 
tuberculosis mortality. 

There are various prognostic factors : (a) The virulence of the pneu- 
mococcus, which varies from year to year (5 per cent, mortality in one 
year, 31 per cent, in another, Brandes). The mortality of 85,000 cases 
in the German army was 3i G o per cent., but these are necessarily 
selected cases. In hospitals the mortality ranges between 20 and 40 
per cent., and is due to alcoholism, to excesses, and to overwork. In 
465,400 collected cases, E. F. Wells found 20 per cent, the average 
death-rate. 

(b) Age. — According to Fraenkel, the mortality is: one to five 
years, 30 per cent. ; five to ten years, 3 per cent. ; ten to twenty years, 
5 per cent.; twenty to thirty years, 8 per cent.; thirty to forty years, 
25 per cent.; forty to fifty years, 39 per cent.; fifty to sixty years, 43 
per cent. ; sixty to seventy years, 53 per cent. ; seventy to eighty years, 
87 per cent. The aged succumb readily; long ago Cruvelhier spoke 
of pneumonia, in this connection, as the most formidable scourge, 
and Peter characterized pneumonia as the natural end of old people. 
Morse, in 118 children, found the mortality 36 per cent, in the first 
year and 19 per cent, in the second; Reviere, 25 per cent, in the first, 
15 per cent, in the second year, and 2 per cent, in older children. 

(c) Sex. — The mortality is 50 to 100 per cent, higher in women; in 
pregnancy the disease is always severe. 

(d) Location. — Right-sided pneumonia is more fatal than left- 
sided pneumonia, and the upper- is more fatal than lower-lobe 
involvement. Extension from lobe to lobe is serious. 

(e) Unfavorable Conditions. — These are hepatic cirrhosis and ne- 
phritis, in which the death-rate is almost 100 per cent.; delirium 
tremens and inveterate alcoholism, in which it is 45 to 50 per cent., 
cardiovascular disease, scoliosis, and high altitude, render the dis- 
ease dangerous. 

(/) Unfavorable Symptoms. — These are long prodromata, hyper- 
pyrexia, enteritis, marked jaundice, albuminuria, severe pain, marked 
cyanosis, pulmonary oedema, diffuse bronchitis, and a white cell- 
count under 10,000. Sears and Larabee found the mortality 9 per 
cent, with the respirations under 30, 15 per cent, under 40, and 60 per 
cent, over 60 per minute; and 50 per cent, with the pulse over 130. 

(g) Unfavorable Complications. — Endocarditis and meningitis are 
almost always fatal; abscess, gangrene, and arthritis are always serious; 
pericarditis is fatal in 50 to 75 per cent, of the cases. 

Strictly speaking, death is due in almost all cases to cardiac toxaemia. 
Mechanical overwork of the heart or diminished respiratory space are 
of small importance. 

Treatment. — (A). Prophylaxis. — Prophylaxis concerns disinfection 
of the sputum, cleansing of the room, isolation, and maintenance of 
the physiological resistance. Cleansing of the nose may be of value 
in prevention. 



PNEUMONIA 155 

(B). Serotherapy. — Serotherapy has not proved successful, and 
pneumonia remains a self-limited disease. 

(0). Hygiene. — The hygiene is the same as in typhoid. Quiet 
should be maintained, the mouth, especially, should be cared for, and 
the patient should be clothed with a light flannel jacket open down 
the back. 

(D). Diet. — The diet consists of milk, eggs, and cereals. 

(E). Symptomatic Therapy. — 1. The Chill. — The chill is rarely 
seen by the physician, but the same measures are indicated as in 
malaria. 

2. Cough. — For the cough, nauseating expectorants are to be avoided 
and codeine gr. J, and carbonate of ammonium gr. iij, should be given 
every two to four hours. If these are ineffectual, or disturb the stom- 
ach, morphine is indicated (v.i.). 

3. Pain. — For pain, the chest should be firmly strapped with adhe- 
sive plaster, applied in several oblique directions so that the pieces 
cross each other. Morphine does not essentially depress respiration 
but rather lessens the irritability of the respiratory centre and re- 
lieves pain. Poultices can be more easily endured than ice, but 
neither are essential. Blisters, leeches, and the Paquelin cautery are 
superfluous. In pneumonia, general is far more important than local 
treatment. 

4. Heart. — Care of the heart is the main objective in the treatment. 
Constant watching is imperative lest the delirious patient leave his 
bed, and it is a safe rule to consider all pneumonics delirious. Sitting 
up to drink, defecate, or urinate, should never be allowed, as pneumonia 
is a disease of sudden and alarming changes and there is constant 
danger of sudden death. No therapeutic measure should be em- 
ployed which depresses the heart, and therefore antipyrin, antimony, 
aconite, and pilocarpine, are always to be avoided. 

Cardiac Stimulation. — Strychnia. — Strychnia, grs. -Jo to so every 
two, three, or four hours, is the best heart tonic, and should be 
given in every case because of the cardiac and vasomotor instability 
which often develops without warning. Vasomotor paralysis and 
collapse are attended by accumulation of blood in the abdominal 
vessels. Von Basch observed that pallor of the retinal vessels followed 
section of the splanchnic nerve. Gottlieb prefers caffeine and camphor 
to strychnine for vasoparesis. He holds that the dosage of strychnine 
necessary to constrict the vessels is too nearly the dose likely to pro- 
duce convulsions. The opinion of the distinguished pharmacologist 
will not receive general support from clinicians and practitioners. 
In the collapse caused by acute toxaemia or other conditions, the vaso- 
dilatation is general, but particularly concerns the deep abdominal 
vessels. Strychnine is here indicated, not only because of its general 
effects but because of its powers of vasoconstriction on the deep ves- 
sels, since it is known that the drug tones the abdominal vessels, 
(while the vascular tonus in the skin and brain is not increased), and 
thereby flushes the brain vessels and stimulates the bulbar vasomotor 



156 THE SPECIFIC INFECTIONS 

and other vital centres. Cold has an analogous effect on the splanch- 
nic nerve. The drug stimulates (1) the central nervous system; (2) 
the digestive tract, the secretions, and peristalsis; (3) the circulation, 
the heart-muscle, and chiefly the vasomotor centre, and (4) the respi- 
ratory centre. 

Administration. — Some strychnine remains in the system from three 
to eight days, though some is destroyed at once by the liver, and some 
is quickly eliminated by the kidneys. If the kidneys or liver are dis- 
eased or functionally tardy, as they are in old age, the drug may ac- 
cumulate. Full doses sometimes produce nervousness, irregular heart, 
palpitation, or renal-vessel spasm, as does digitalis. Strychnine is 
absorbed more quickly by rectum than by the stomach. Hypodermic 
administration gives less chance for the liver to destroy the drug than 
does administration by mouth. 

Ammonia. — The preparations of ammonia are of the greatest clin- 
ical importance. They temporarily stimulate the heart-muscle, in- 
crease its frequency, and constrict the vasomotor system, thereby 
raising arterial tension. Its effects are soon observed in local flush- 
ing, subjective warmth, tension in the temples, a sense of exhilaration, 
and increase in the urine, sweat, and mucous secretion. The prime 
indication for ammonia is sudden and functional cardiac adynamia, 
which occurs at the crisis. It is a local irritant to the skin and to the 
subcutaneous tissues as well as to the respiratory and alimentary 
mucosae, and therein lie its therapeutic value and its clinical disad- 
vantages. Its irritant or stimulant properties upon the nose, mouth, 
and upper respiratory tubes cause a sudden reflex stimulation of the 
respiratory and circulatory centres, which follows its application to 
the nose, and its use as smelling-salts; and cause the centripetal 
stimulation, which travels from the throat, oesophagus, and stomach, 
to the brain, long before the drug is absorbed. Untoward action is 
frequently observed in gastric, intestinal, renal and bronchial irrita- 
tion resulting from overdoses, and also in undue irritation or necrosis 
following subcutaneous administration. The corrosiveness and fugi- 
tive action of ammonium carbonate are both very relative contraindi- 
cations, and are obviated by administration of small and frequent 
doses, gr. iij every two hours. 

Digitalis. — Digitalis was recommended by Traube and Petrescu, 
who considered 75 to 150 (!) grains necessary for good results. The 
administration of these large doses simply proves, in the author's 
opinion, that the digitalis is not absorbed. It is claimed that exuda- 
tion is modified and that leukocytosis is increased. Personally, the 
author has never seen digitalis produce such good result as strychnine 
does, but he has repeatedly noticed toxic symptoms appear at the 
crisis when the repeated doses were absorbed together. Collapse 
may occur. Digitalis should be used only as a last resort, w ij to v of 
fluid extract (the most reliable preparation) should be given hypoder- 
matically. The author believes digitalin is almost inert (see Treat- 
ment of Valvular Heart Disease). 






PNEUMONIA 157 

Alcohol. — The chief interest centres in its action upon the circu- 
lation. For years it has been called a heart stimulant, though important 
objections have been raised to this statement. The frequency of the 
heart's action is increased, but it is known beyond all doubt that the 
drug acts as a vasodilator or as a blood distributor. No pharmacol- 
ogist now holds that alcohol stimulates the hear! as do digitalis, 
strychnine, or camphor. Some clinicians use alcohol for weakened 
circulation in typhoid, pneumonia, or sepsis, and obtain good results. 
Other practitioners refuse to employ it because it is narcotic to the 
nervous system and to the vital respiratory, circulatory, and vasomotor 
centres in the lower brain. Some of the latter class refuse to use it 
on account of prejudice and others base their opinions on the labora- 
tory results given above. It must be admitted, however, that alcohol 
has some good effects. Direct cardiac stimulation by alcohol per se 
is impossible, except in preparations like champagne which contain 
other ingredients. Alcohol was first recommended by Todd for fevers. 
It is effective in all varieties of sepsis. It protects tissues from exces- 
sive waste and is well tolerated in nearly all cases. There is no danger 
of cardiac collapse when it is withdrawn in convalescence. Jurgen- 
sen gives it in all cases, using red Bordeaux wine as a routine proce- 
dure, especially if cool baths are employed. If the heart becomes 
weaker, Bordeaux is replaced by the stronger sherry or port; then by 
rum, cognac, champagne, or whiskey in hot water, and tea or coffee, 
which can also be given by rectum. Alcohol is invaluable, whatever 
its action; it is second only to strychnine and is indicated by collapse 
or cardiac toxaemia in which hot whiskey and water unquestionably 
stimulate by reflex action on the throat and stomach. 

Ether. — Dram doses may be injected for urgent cardiac symptoms, 
but it is apt to produce sloughing. 

Opiates. — It is the author's personal belief that opium and morphine 
are not sufficiently recognized as vascular and cardiac tonics. Many 
clinicians withhold opiates in pneumonia even when the drug is indi- 
cated by maniacal outbursts, active delirium, and harrassing coughing 
or pain, because it depresses respiration, and ill effects upon the circu- 
lation are feared. When used freely, it decreases the irritability of the 
respiratory centres, and thereby lessens cough and dyspnoea, and the 
attendant headache and insomnia, and it almost invariably acts as a 
strong cardiovascular tonic. Its effects on diseased kidneys are not 
to be feared with ordinary care in administration. Morphine will 
of itself help to sustain life, and in several most critical cases, where 
the author has watched its effects for consecutive hours, its hypodermic 
use has strengthened and regulated respiration even when Cheyne- 
Stokes respiration was marked. When the heart weakens, its force 
will often be renewed by morphine. It is a most valuable adjunct to 
the true cardiovascular stimulants, either those which have continued 
action, as strychnine and digitalis, or those whose action is more fugi- 
tive, such as camphor, ammonia, or caffeine, which latter has an 
excellent effect, given by rectum, in neutralizing the effects of opiates. 



158 THE SPECIFIC INFECTIONS 

Camphor, — Camphor in grains i to ij, hypodermatically in 10 
parts of sterilized oil, every two to four hours, is an excellent diffusive 
stimulant for the heart and brain. 

Saline Infusions. — These are indicated in profound toxaemia with 
weak heart. Two drams of salt in one quart of water are the rough 
proportions of the physiological salt solution. They are the "lavage 
of theblood" of French writers, who combine them with venesection. 
Although once violently abused, venesection, which has been employed 
since the time of Hippocrates, has again come more into vogue. It 
is valuable at the very onset in the robust for severe pain, active de- 
lirium, and urgent dyspnoea, and later when great engorgement of 
the right heart occurs. It rather promotes heart thrombosis and de- 
layed resolution. Heart stimulants must be used with phlebotomy, 

Oxygen. — Oxygen is said to relieve dyspnoea, and has been used 
as an adjunct to the heart stimulants, but recent studies have shown 
that it is often irritating and injurious. A mouth-piece should not be 
employed, or at least not held closely over the mouth, but merely 
near it. 

Atropine. — Atropine is valuable in collapse with low temperature 
and clammy skin. The aggregate dosage should not exceed one- 
fortieth of a grain. 

5. Antipyretics. — A high temperature is not per se injurious. In- 
deed, Cantani proved that cases with fever between 103° and 105° pro- 
gress most favorably and that those with temperature above or below 
these limits have a more severe course. Von Jiirgensen insists that 
all measures or remedies which suddenly reduce the temperature must 
be avoided. They are especially injurious at the crisis, when the 
heart sometimes staggers under the sudden fall of the fever. 

Hydrotherapy is opposed by many. Marchand considers that it 
promotes chronic induration of the lung, though Liebermeister les- 
sened the mortality in his cases by 9 per cent. The tonic vasomotor 
effects are thought to outweigh the element of shock. It is less indi- 
cated in children and is contraindicated in the very obese, the weak, 
or the aged. Cool sponging with water and alcohol is the safest method. 
Quinine gives no antipyretic effect except in doses of thirty grains 
or more. Its administration is advocated by Aufrecht, Jiirgensen and 
See, who give thirty grains at 6 to 8 p.m., thereby bringing about a 
slow reduction of temperature without cardiac depression. Aufrecht 
combines it with iron. 

6. Nervous Symptoms. — These are toxsemic, but should be con- 
sidered with regard to: (a) fever; the greater the temperature varia- 
tion, the more marked are the nervous symptoms; febrile nervous 
symptoms are most efficaciously treated by baths or cool affusions; 
(b) ansemia, the delirium of which is relieved by morphine, coffee, 
alcoholic and saline infusions; (c) deficient oxygenation, in which 
cold baths, cardiants, and oxygen inhalations are indicated; (d) in- 
somnia, which is treated by morphia, bromides, hyoscine hydrobro- 
mate, sulphonal, and cool sponging, but never by chloral; (e) delirium 



DIPHTHERIA 159 

tremens (q. v.), in which rest is absolutely necessary and is best secured 
by the drugs named under (d) and by alcohol. 

7. Tympany. — (See Typhoid.) 

8. Iodides and Cod-liver Oil. — These should be given in delayed 
resolution. 

DIPHTHERIA. 

Definition. — An acute specific infective disease, which usually be- 
gins in the throat or upper air-passages, and is characterized by a 
local yellowish adherent membrane which is due to the Klebs-Loeffler 
bacillus, and by constitutional symptoms due to toxaemia. 

History. — Diphtheria was known to Hippocrates. Asclepiades, 
100 B.C., performed the first tracheotomy. The name diphtheria 
literally means membrane and originated with Bretonneau (1821). 

Terms and Restrictions. — True diphtheria implies a membrane 
formed by the Klebs-Loeffler bacillus whose absorbed toxins usually 
also produce toxaemia. There are, however, membranes not formed 
by this bacillus but due to the scarlatinal virus, streptococci, pneumo- 
cocci, staphylococci, caustics, etc. While these are diphtheritic mem- 
branes in the old anatomical sense, they are not diphtheritic in the 
bacteriological sense. We must then term them pseudodiphtheritic 
or necrotic inflammation, or diphtheroid. Therefore, clinically, there 
are some discrepancies: (1) what seems diphtheria, anatomically, may 
prove not due to the Klebs-Loeffler bacillus; (2) some apparently 
simple throat inflammations, resembling angina or tonsillitis, may 
show no membrane or atypical membrane, but bacteriologically are 
found due to the Klebs-Loeffler bacillus, — i. e., are true diphtheria; 
(3) the diphtheria bacillus is found in 1 per cent, of perfectly healthy 
throats; (4) there are bacilli which closely simulate the diphtheria 
bacillus (v. i.). The pseudodiphtheritic or diphtheroid membrane is 
most often due to the streptococcus and is seen oftenest in scarlatina, 
but also in typhoid, measles, Vincent's angina, syphilis and pertussis. 
It develops not merely in the throat, but wherever the true diphtheritic 
membrane may occur, — e. g., the larynx, bronchi, eyes, skin, etc. As 
a working statement, most cases clinically resembling diphtheria are 
proved diphtheria by close and repeated bacteriological tests. G. 
Smith found the bacillus in 72 per cent, of 27,000 collected cases, 
though Parks and Bebee find 40 per cent, of membranes diphtheroid — 
a high estimate. 

Bacteriology.— The diphtheria bacillus (described by Klebs, 1S83, 
and cultivated by Loeffler, 1884), is 1.2 to 2// long and 0.3 to 0.5,u 
wide, with small round ends, or ends slightly enlarged. It stains 
readily by Gram's method, by Loeffler's methylene blue, and by carbol 
fuchsin. There are many irregular variations in form, such as branch- 
ing types, but the serum culture always reveals the wedge or mallet- 
like forms. Some are very long, others short and parallel. Their 
grouping is characteristic, like Chinese letters, in lines set asymmetri- 



160 



THE SPECIFIC INFECTIONS 



cally at various irregular or slight angles. They are immotile and 
sporeless. Cultivated in all media, the diphtheric bacillus overgrows 
other associated bacteria on blood serum. On blood serum mixed 
with glucose bouillon, the culture is visible in eight to ten hours as 
yellow streaks, whose surface is slightly granulated and whose edges 
are somewhat thick. In twenty-four hours the growths have spread 
everywhere, with a wavelike surface, high, undulating edges, and a 

Fig. 17. 




Bacillus diphtheriae: A, its morphology on glycerin-agar-agar; B, its morphology on Loeffler's 
blood-serum; C, its morphology on acid blood-serum mixture (Abbott). 

succulent, glistening appearance. The diphtheria bacillus is very 
resistant, and though it usually disappears in two or three weeks 
after the patient has shed the membrane, it may live for weeks or 
months in the throat (even six to fifteen months) or for a long period 
in clothing. It is found chiefly in the throat membrane, and is less 
frequently detected in the submucosa, heart (endocarditis), blood, 
lungs (bronchopneumonic foci), spleen, liver, brain, cord, kidney or 
urine. In one report, it was said to have been found in the blood 
and viscera eleven times in fourteen cases. Its presence in these parts 
has been explained by what we may call diphtherisemia, by post-mor- 
tem migration, or by association with other bacteria, of which the 
streptococcus is the most important, being found in septic types, in 
bronchopneumonia, and in glandular suppuration. Symbiosis with 
the streptococcus, which is the most common of all secondary infections 
and enters by the throat mucosa, increases the virulence of the diph- 
theria toxin (Roux and Yersin). Less important are the staphylo- 
cocci — which rarely enter through the throat, but when they do, are 
extremely virulent — the proteus, colon bacillus, and pneumococcus. 

The action of the bacillus is (1) local, disturbing the tissue, produc- 
ing necrosis, and forming membrane; when inoculated in animals, 



DIPHTHERIA 



161 



local necrosis develops, whereon fibrin exudes and forms a membrane 
in which the bacillus is found; the contiguous tissues are cedematous; 
(2) general, forming toxins which are absorbed by the blood and lymph- 
vessels. Roux and Yersin (1888) found that the toxins injected alone, 
after killing the bacillus, produce a general intoxication, but no mem- 
brane or necrosis. They succeeded in producing a paralysis precisely 
similar to the post-diphtheritic paralysis. According to Ehrlich there 
are two toxins; one, the toxin, produces the ordinary acute phenomena 
of diphtheria; and the other, the toxon, produces the later anaemia 
and paralysis. The chief receptors of the virus are the nervous and 
lymphatic tissues. 

The virulence of the germ varies. This is tested on the guinea-pig 
by inoculating it with ooo of its body-weight of a forty-eight-hour 
bouillon culture, and by noting the results: (1) death in three days 
or less results from fully virulent cultures; (2) death in three to five 
days from one of medium virulence; (3) death after a longer time, or 
only local changes from weak cultures. 

Some bacilli, known as the pseudodiphtheria bacillus, bacillus 
xerosis, etc., microscopically resemble the Klebs-Loeffler bacillus. 



Pseudodiphtheria Bacillus. 



-Diphtheria Bacillus. 



Luxuriates on gelatin and peptone agar. Sparing growth. 



Produces either an alkali or very little 
acid in culture. 



"Klatsch preparat" (adhesion prepara- 
tion) does not develop in six or eight 
hours, and if it has, the bacilli are 
arranged irregularly. 

Are not pathogenic to guinea-pigs. 
(Some claim this type is only an 
attenuated form of the real bacillus.) 

Smaller. 



Growth on bouillon should produce in 
twenty-four hours enough acid to 
neutralize 0.07 gm. of a 1-per-cent. 
sodium hydrate solution. 

Show the bacilli in colonies arranged 
in parallel or crossed lines within six 
or eight hours. 

Kills (v.s.) in seventy-two hours. 
(Some apparently genuine forms may 
be nonvirulent.) 



In the pseudodiphtheria bacillus Neisser's stain does not bring 
out the granules which are present in the true diphtheria bacillus, 
in ox-serum growths under twenty hours old; the body of the diph- 
theria bacillus stains brown and its two to four polar granules stain 
a deep blue. (Stain preparation for one to three seconds in a solu- 
tion of methylene blue 1.0 gm., 96 per cent, alcohol 20.0, glacial 
acetic acid 50.0, and water 950.0. Wash in water and stain again 
for from three to five seconds in solution of vesuvin 2.0 and 1000.0 
gm. boiling water.) Another interesting and vital point is that pseu- 
dodiphtheria bacilli may become virulent and may kill; they are not 
neutralized by the diphtheria serum but only by the pseudodiph- 
theria serum (Alice Hamilton, Spronek, Ruediger). 

Dissemination. — Diphtheria is disseminated (1) by patients acutely 
ill with the disease; the nasal, throat and laryngeal secretion or mem- 
li 



162 THE SPECIFIC INFECTIONS 

brane may be coughed into the face or mouth of one of the family, 
of the nurse, or of the attending physician. Infections in which the 
patient is not kept in bed are especially dangerous, for children 
going to school may impart to others a most virulent diphtheria, 
though the same bacilli have produced in them little or no constitu- 
tional reaction; (2) by healthy individuals, in 1 per cent, of whom the 
germ is found without causing diphtheria, since individual predisposi- 
tion is almost as necessary to infection as virulence in the microbe; 
(3) by fomites, especially damp cloths, in which the germ may live 
for months; cultures have been made from dry cloths after five months; 
the germ lives in gelatin from twelve to eighteen months; (4) as the 
germ may be cultivated in dust, it is probable that it may be spread 
by the wind. Although the bacillus has been cultivated from cheese, 
milk, and eating utensils, many question this mode of propagation. 
It is not demonstrated that domestic animals convey the disease. 
Diphtheria is endemic in all thickly populated districts, and from 
these, epidemics develop from time to time. Unlike scarlatina, which 
is growing milder, diphtheria epidemics are apparently growing in 
virulence, although they are far less malignant than in the middle ages 
and earlier modern times. 

Age. — Most cases occur between the second and fifteenth years; 
and most deaths occur between the second and fourth years. Adults 
are frequently affected. Jacobi has seen three cases in the new-born, 
but infants at the breast are far less exposed. Creeping children are 
frequently attacked, because their hands and mouths come into close 
contact with dirt and dust (Jacobi). It develops more frequently in 
girls than in boys. 

Season. — Most cases occur in the cold months. Predisposition, 
bad teeth, stomatitis, hypertrophied tonsils, nasopharyngeal and 
bronchial catarrh, measles, and nervous affections, are predisposing 
factors. Some individuals are temporarily, and some permanently, 
immune. One attack confers no immunity, and in this respect diph- 
theria resembles erysipelas, pneumonia, and rheumatism. 

Symptoms. — Baginsky's classification of (1) local infection, (2) 
general infection, and (3) septic infection, is better than the old 
division into mild, moderate, and severe forms. Incubation lasts from 
two to seven days. 

1. The simple localized diphtheria begins with fatigue, sopor, 
pallor, coated tongue, anorexia, dysphagia, pain beneath the angle 
of the jaw, and vomiting. These may be the only symptoms, but 
usually there are also chilly sensations, fever and thirst, dry tongue 
and lips, pharyngeal voice, sometimes constipation and abdominal 
distention. Infants sometimes refuse the bottle on account of nasal 
obstruction. 

The pharynx is moist, glistening, cedematous, and reddish, with 
areas of gray, yellowish-gray, or dirty green color, which vary in extent 
from small white bands to irregular, gelatinous elevations or masses, 
and are located on the tonsils, epiglottis, palate, pillars, arch, or 



DIPHTHERIA 163 

pharynx. They are adherent, and, on removal, leave red, bleeding 
spots which are soon covered again with membrane. The pharyngeal 
tonsil alone may be involved, and this infection may easily be over- 
looked without careful systematic examination. 

The typical membrane is accompanied by fibrinoid swelling of the 
tissue, fibrin formation, emigration of cells, and necrosis. The Klebs- 
LoefHer bacillus is found on the surface in pure cultures, and strepto- 
cocci and staphylococci may be found more deeply situated. 

Wagner, Weigert, and Oertel, have shown that the diphtheritic 
membrane is composed: (a) of necrobiotic tissue. The superficial 
epithelium, and, later, the deeper structures, are necrosed; the bacilli 
are found in the superficial layers, and the necrobiosis may be also 
noticed in the connected lymph-glands, and in the internal organs 
(Weigert's coagulation necrosis, or hyaline transformation of the dead 
cells). (6) Somewhat deeper, the membrane is composed of more 
or less marked fibrin exudation, which is probably a conservative, 
walling-off process, which also pervades the tissue initially necrosed, 
(c) In the deepest part of the membrane, emigration of leukocytes 
occurs. In most adults the membrane is thrown off by the fourth or 
fifth day; in children by the seventh or eighth day. 

The nose is not wholly free. The glands at the angle of the jaw are 
tender, and fever may reach 102° or 103°, may be rather irregular, or 
may be absent. The patient usually recovers in seven to ten days. 
Otitis, suppurative adenitis, vomiting, and albuminuria, are less com- 
mon than in the more severe forms. 

The form described is the classical type of mild local infection. 
Even though the bacilli may be virulent, the tissues and blood resist 
the infection. There are several deviations from this type which are 
often clinically misinterpreted: (I) In "catarrhal diphtheria" the 
membrane is often absent. This type is especially common in families 
where the more severe forms are seen. The bacilli, and redness, 
oedema, and swelling, are present. If a membrane develops, it may 
be atypical and pultaceous. (II) Diphtheria may resemble follicular 
pharyngitis, and between them there is no absolute distinction except 
a bacteriological one; in diphtheria, however, the red is brighter, 
the tendency to fuse is greater, and the spots are yellow, gray, or green, 
while in angina, the color is duskier, the areas more discrete, yellow, 
and pus-like. (Ill) Follicular tonsillitis may be very closely simulated, 
and may be only distinguished bacteriologically. (IV) In chronic 
diphtheria, there is a variable deposit upon a red, relaxed, cedematous 
pharynx. This deposit may spread over the tongue. The glands 
may be swollen, but usually there are no general symptoms. (V) 
The latent diphtheria of Huebner, which occurs in marantic subjects, 
may easily escape detection. 

2. The diphtheritic general infection is difficult to describe in all its 
variations. It begins with high fever and such febrile toxemic symptoms 
as headache, depression, insomnia, sopor, rapidly increasing anaemia, 
anorexia, dysphagia, and vomiting. Albuminuria and nephritis may 



164 THE SPECIFIC INFECTIONS 

appear later, with rapid respiration and the heart movement following 
the fever, the tones being dull and often accompanied by a systolic 
murmur. The pharynx is dark red, swollen, and glistening, and a 
membrane is seen on the tonsils or pharynx. This membrane is thin 
and gray; it begins in the form of streaks, or as a thin veil over the 
pharynx; it tends to spread very rapidly and sometimes results in a 
diffuse membrane with off ensi ve secretion. It usually leaves exempt the 
hard palate as well as the superior part of the soft palate. The neck 
is tender from glandular intumescence. The nose is often closed by a 
purulent secretion and diffuse membrane, and oral breathing results. 
There is a type peculiar to young children who, with initial nasal 
symptoms and without appreciable throat symptoms, suddenly develop 
laryngeal stenosis, and, in the pre-antitoxin days, almost invariably died. 
In severe cases the heart is irregular with gallop-rhythm; there are 
throat paralysis, infiltration of the neck, dyspnoea, cyanosis, albu- 
minous urine, tympany, swollen liver and spleen, ante-mortem fall 
of temperature, and death resulting from (1) pneumonia, (2) cardiac 
insufficiency, (3) nervous symptoms or paralysis or (4) nephritis. 

3. Septic diphtheria, according to Baginsky, is due not to mixed 
infection but to the diphtheria toxins, and is therefore seldom observed 
since the introduction of antitoxin. Other writers maintain that strepto- 
coccus and staphylococcus infection determine this septic type. The 
yellow-gray exudate becomes a dirty green or brown from hemorrhage, 
is ichorous and horribly fetid, and may reach the nose or larynx, causing 
erosions, necroses, and stenosis. It often involves the lymph glands 
(adenitis) and connective tissue (periadenitis). The tongue is dry; 
respiration difficult; and nephritis, generalized hemorrhage, or local 
arterial ulceration, failing pulse, low temperature, swollen joints, and 
intumescence of the abdomen, liver, and spleen, usually result fatally. 
In 1884, 66 per cent, and, in 1881, 94 per cent, of cases of this type died 
(Glaeser). 

Special Symptoms. — 1. Fever. — The fever in diphtheria is not 
typical. It often rises to 103° and remains there for one or two days, 
when it falls by lysis, to rise moderately again from the fourth to the 
seventh day. It may be maintained by otitis, pneumonia, adenitis, and 
other complications, or by concomitant diseases, such as measles, 
scarlatina, or tuberculosis. The temperature of sepsis may develop. A 
preagonal perturbation may be observed, or there may be ante-mortem 
collapse. Algidity is due to febrifuge toxins, as it is in perforative 
peritonitis. These statements apply chiefly to cases untreated with 
antitoxin. 

2. The Blood. — Leukocytosis develops in 90 per cent, of diphtheria 
cases, and is of the polymorphonuclear type. When absent, the infection 
is either very severe or very slight. It does not correspond to the sever- 
ity of the disease nor to the fever curve. It disappears in favorable 
cases, and persists in those which are severe. 

Special Localizations of Diphtheria. — 1. Diphtheritic Rhinitis. — 
Diphtheritic rhinitis, catarrhal or croupous, due to the diphtheria 



DIPHTHERIA 165 

bacillus, may usher in the disease or accompany the benign or more 
usually the severe forms. The serous and often sanious or bloody nasal 
discharge excoriates the alse nasi, lips and cheeks; membrane is often 
expelled; infection may travel to the eyes, lachrymal sacs, antrum, or 
ears. Cervical adenitis is frequent, for the nasal lymph supply is most 
abundant and, as Jacobi pointed out, enlargement of the angular glands 
is always suspicious. The prognosis is nearly always grave, and con- 
valescence very tardy. In contrast with this severe form, usually diph- 
theritic, though sometimes diphtheroid (streptococcic), there is a 
fibrinous rhinitis usually subacute or chronic and generally observed 
in children, which is due to the Klebs-Loeffler bacillus (82 percent.), 
though sometimes to the streptococcus (18 per cent, of the cases); the 
membrane is abundant. This form is obviously dangerous to other 
children, since the remarkable absence of constitutional reaction does 
not prevent play or school-going. It responds readily to antiseptic 
douches. 

2. Diphtheritic Croup (Diphtheritic, laryngo-tracheo- bronchitis). — 
Most cases (85 percent.) of croup are diphtheria, though some are due to 
streptococcic infection; their symptoms are identical. Frequency: 
Diphtheria involves the throat in 84 per cent, and the larynx in 16 per 
cent, of the cases. Forms: (a) Catarrhal laryngitis, due to the diph- 
theria bacillus, produces symptoms of short duration, usually two or 
three days; they may be severe or even stenotic. (6) Diphtheritic 
laryngitis (croup) is usually descending (97 per cent, of cases) — i.e., 
secondary to throat or nasal diphtheria, but may on rare occasions be 
primary in the larynx; even in these cases there is usually some pharyn- 
geal involvement. The ascending form is most exceptional. The child 
is usually hoarse at night or early in the morning, coughs the croupy 
cough, and then after twelve to twenty-four hours is distinctly dys- 
pnceic. The accessory muscles of respiration come into play and there 
is inspiratory retraction of the thorax and epigastrium, especially in 
rhachitic children. Excursion of the larynx up and down, extreme 
restlessness, and temporary improvement after expectorating the mem- 
brane, may also be noted. The stenosis is due to membrane in the 
epiglottis, true cords, trachea, or even in the bronchi. The membrane 
is less adherent than when it is in the pharynx, and sometimes more 
pultaceous. The stenosis is accentuated by the central and immovable 
position of the vocal cords, by swelling in the subchordal tissue, and by 
muscular spasm. Aphonia is common but not invariable. The cough 
is usually rather hoarse than metallic, is often periodic, is increased after 
tracheotomy, or intubation, and often evacuates both the membrane 
and tube. Cough may be wholly absent because of decreased reflex 
bronchial excitability. 

Temperature is usually absent though it may arise from compli- 
cations. Fever after tracheotomy or intubation is ominous. The pulse 
rate increases with augmentation of the stenosis because the vessels 
contract from central stimulation. The respite following the raising 
of the membrane is usually transient, exacerbations occur, and finally, 



166 THE SPECIFIC INFECTIONS 

dyspnoea becomes continuous with stagnation of secretion in the tubes, 
absence of the vesicular murmur, stridor, extension downward of the 
membrane in some instances, loss of strength, increasing rapidity and 
weakness of the pulse, cold, clammy skin — in short, the complete 
picture of carbon dioxide poisoning and total asphyxia. In some 
instances, perichondritis, deep necrosis, or gangrene may develop. (In 
reading older medical works and pathologies, the student may be con- 
fused with the use of the terms " croup " and " diphtheria. " Anatomi- 
cally it was held that croupous and diphtheritic membranes differed 
chiefly in degree — croupous being more superficial and benign, diph- 
theritic being more deep and malign. In the present connection we use 
the term "croup" as synonymous with laryngeal diphtheria.) 

3. Diphtheria of Skin. — True diphtheria caused by the diphtheria 
bacillus may produce a membrane on the eye, lips, nose, mouth, navel, 
neck, genitalia, and extremities. It is usually associated with the more 
common throat localization. The skin is hard and infiltrated, the 
secretion is corrosive, the contiguous lymphatics are involved, and some- 
times cellulitis or phlegmon may result. Other cases of so-called 
"wound diphtheria" are due to the streptococcus, which is the most 
common cause of skin membranes. In tracheotomy, the membrane 
which forms in the wound is mostly streptococcic. 

4. Diphtheritic Vulvo-vaginitis. — Genital involvement is rare (under 
1 per cent.), is dangerous, and may be primary, but usually follows 
severe pharyngeal diphtheria; it consists of diffuse membrane, pain- 
ful rhagades, ulcers, and foul secretion, with intumescence of the 
lymph glands. A diphtheroid (usually streptococcic) form is also 
encountered. 

5. Diphtheritic Ophthalmia. — This localization is (a) false or diph- 
theroid (due to pus cocci) or (b) genuine or diphtheritic. It may here 
be noted that the old division into croupous (benign), and diphtheritic 
(malign) forms is no longer valid. Diphtheritic ophthalmia, chiefly in 
young children, occurs in 3 per cent, of cases. It may be primary in the 
eye, or secondary to nasopharyngeal diphtheria. 

6. Diphtheritic Otitis. — This does not occur in over 5 or 6 per cent, of 
the cases (as against 33 per cent, of otitis in scarlatina and nearly 100 
per cent, in measles). The orifice of the Eustachian tube or the middle 
ear may be reached by the diphtheria bacillus which usually travels 
from the throat. 

Complications and Sequels. — The most important are diphtheritic 
paralysis, heart paralysis, and nephritis. 

1. Diphtheritic Paralysis. — The paralyses result clinically and 
experimentally from toxaemia, and occur in 3 to 10 per cent, (even 20 
per cent.) of cases. The percentage, apparently, has not been reduced 
by the use of antitoxin (v. i.). The frequency and intensity of the 
paralysis is usually directly proportional to the intensity of the diph- 
theria but there is no invariable relation between the palsy and the 
severity of the infection. Indeed the causal diphtheria, in some cases, 
Las apparently escaped detection. 



DIPHTHERIA 167 

(a) Early Diphtheritic Paralysis. — This occurs in septic cases at the 
acme. Dysphagia is its most common form. There is danger of in- 
halation pneumonia, especially in stupid cases. Other changes may 
occur, such as the disappearance of the patellar reflexes, and changes in 
sensation. Most cases die. 

(b) Post-diphtheritic Paralysis. — This variety occurs after two or 
three weeks and usually follows throat lesions since laryngeal cases are 
likely tp die early; Baginsky saw it principally in adults and Rolleston 
mostly between the ages of three and six years. Gowers claims that all 
throat troubles leading to paralysis are diphtheritic, though Bourges 
and others cite cases of paralysis after simple angina. The most com- 
mon paralysis is that of the palate, which causes dysphagia, anaesthesia 
of the throat, and nasal speech. From central or peripheral change the 
pupils become wide and react to light but not to accommodation 
(Donders). The arms may be affected, but frequently escape. Ataxia 
may be the first symptom. Heart or central nervous symptoms may 
appear (v. L). The reflexes disappear early whether actual paralysis is 
reached or not, the muscles react slowly, if at all, to the faradic current, 
although the reaction of degeneration runs by no means parallel to the 
degree of loss of voluntary motion. The muscles waste considerably. 
The sensory nerves suffer less, sensation being largely retained above 
the knees. The palsied limbs are sometimes painful and the muscles 
and nerve trunks are often tender. Sensory disturbance may be noted 
in the rectal, genital, and vesical twigs. The trunk, bladder, and rectum 
are more commonly involved than is usually admitted. The cranial 
nerves (strabismus, ptosis, diplopia), the phrenic nerves and the vagus 
(recurrent paralysis, superior laryngeal, cardiac branches), may be 
involved; fearful abdominal pains with threatening collapse attribut- 
able to sympathetic involvement, and sometimes psychical disturbance 
may be noted. Anatomically, disintegration of the medullary substance, 
multiplication of nuclei in Schwann's sheath, granular degeneration, 
and even total loss of the axis cylinder and sometimes foci of hemor- 
rhage, are present, the changes being almost totally parenchymatous. 
Diphtheritic neuritis (actual nerve inflammation) is seen almost 
wholly in the palate and is due to local invasion from the inflamed 
throat. The patient recovers in two to three weeks if the pharynx alone 
is involved, and in three to four (even six to eight) months if the limbs 
are affected. Death results in 18 per cent, of the cases, chiefly from 
vagus involvement. 

(c) Organic Central Changes. — The brain is slightly congested and 
cedematous. Degenerated areas may occur in the crura, medulla, pons 
or the motor nerves, and are less marked in the sensory nerves. Acci- 
dental findings are cerebral hemorrhage, embolism from heart thrombi, 
and acute encephalitis (possibly terminating in focal sclerosis). In the 
spine, hemorrhage, exudation into the nerve roots, meningitis, and 
degeneration of the motor cells, with disintegration of their roots, have 
been noted. The degenerative cerebrospinal lesions occur not infre- 
quently with multiple neuritis. 



168 THE SPECIFIC INFECTIONS 

II. Cardiac Complications (Diphtheritic Heart Paralysis). — Anatomi- 
cally, the heart muscle is the seat of early changes. It is soft, thin, 
friable, light brown or yellow in color, and fatty; it is the occasional seat 
of endocardial and myocardial hemorrhages, acute interstitial myo- 
carditis and fragmentation or myolysis, which Eppinger, in describing 
eighteen cases of sudden death, considers the usual cause of death. 
Pericarditis, with septic or hemorrhagic effusions, is not frequent. 
Permanent changes due to endocarditis (in 2 per cent, of fatal .cases) 
or to myocarditis are uncommon. 

Clinically, the tones are muffled. The first tone is impure or 
obscured by a systolic murmur (90 per cent, of cases); the second 
pulmonic is accentuated, the rhythm is disturbed (60 per cent.) 
and sometimes there is gallop-rhythm and embryocardia. The 
pulse is soft, dicrotic, increased from 80 to 120, or up to 150 if there 
is fever, but it may be slow. The heart-failure is more frequent than 
it is in any other acute infection, not even excepting pneumonia. 
Syncope on sitting up is fairly common. Diphtheritic heart paralysis 
occurs (1) early in severe or gangrenous types, or (2) late (in 10 to 20 
per cent, of diphtheria cases) after three to four or six weeks, when 
convalescence is apparently established. It is marked by copious vomit- 
ing, pain in the chest and epigastrium, insufficient heart action, cardiac 
dilatation, cold extremities, pallor, dyspnoea, cyanosis and convulsions. 
The pulse is often irregular, fast, or with equally ominous significance, 
slow. Heart failure is explained in various ways (1) acute interstitial 
myocarditis (Rhomberg) ; (2) myolysis (Eppinger) ; (3) sudden centric 
vasomotor paralysis (Hasse); (4) neuritis of the cardiac plexus or of 
the vagus or phrenic nerves; (5) cardiac thrombosis causing cerebral 
or pulmonary embolism; 33 per cent. die. 

III. Diphtheritic Nephritis. — (a) Albuminuria, resulting from renal 
degeneration, occurs in 50 per cent, of all cases and in 100 per cent, of 
severe cases. (6) In light forms of nephritis there is some albumin; 
the specific gravity and quantity of the urine are about normal, and there 
are leukocytes or epithelial cells with indistinct nuclei, the cells being 
highty refractile and coarsely granular. Blood is rarely found. There 
are some hyaline and granular casts. These findings are caused by the 
toxins and correspond in time and degree to the diphtheritic local pro- 
cess in the pharynx, (c) The severe forms of nephritis almost always 
occur in the severe general infection or in septic types and are character- 
ized anatomically by diffuse parenchymatous changes, necrosis, 
hemorrhage, and exudation. Albumin, cells, casts, and cylindroids, are 
abundant. Hematuria is rare, although hemorrhage into the kidney 
substance is frequent anatomically. Although nephritis influences the 
prognosis, diphtheritic nephritis rarely produces hydrops or uraemia and 
" is not an independent factor as in scarlatina." It very rarely becomes 
chronic. 

IV. Respiratory Complications. — The bronchi and trachea may 
remain free. There may be membrane formation (in 50 per cent, of 
fatal cases) or purulent secretion. Lobar pneumonia is a genuine 



DIPHTHERIA 169 

complication, though bronchopneumonia is present in 50 to 80 per cent, 
of the fatal cases and is caused by the Klebs-Loeffler bacillus alone, or 
by the pus or pneumonia cocci, by the colon, proteus or pyocyaneus 
bacilli. Anatomically, some cases are due to downward extension of 
the bronchitis; some cases are hematogenous infarcts or abscesses; 
others are due to inhalation, and still others, seen after intubation or 
tracheotomy, rather resemble lobar pneumonia and are elevated and 
granular in appearance. Increase of pulse and respiration-rate, local 
consolidation, and accession of fever are observed. Pleurisy (serous, 
hemorrhagic or purulent) is not often observed. 

V. Alimentary Tract. — Mouth. — Fissures, sordes, membrane or 
ulcers on the lips, suppuration in the tonsils and in the retropharyngeal 
space, gangrene, and deforming cicatrices, sometimes occur. The 
oesophagus is usually intact, but the diphtheritic process, in septic cases, 
may reach downward and produce stenosis. 

Stomach. — Such symptoms as epigastric pain and vomiting are most 
often cardiac ; such rare organic changes as hemorrhage and membrane 
formation usually escape clinical recognition. 

Intestines. — Constipation is usual ; in septic forms, thick, foul or even 
dysenteric evacuations may be exceptionally observed. Anatomically, 
there may be membrane formation and swelling of Peyer's patches. The 
liver is swollen from fatty or cloudy degeneration or from congestion, in 
which latter case it also becomes painful. Icterus is rare. Splenic 
tumor is found in septic types especially. 

VI. The Skin. — The skin is usually normal, except for the febrile 
hyperemia, cardiac pallor, or croup -cyanosis. The following altera- 
tions may be observed: Herpes, profuse sweats, petechia? and the 
gray-blue color in septic types, symmetrical gangrene and dermato- 
myositis due to septicopyemia; they usually occur with adenitis, 
nephritis, pneumonia, ulcerative endocarditis and scarlatiniform or 
morbilliform erythemata. Scarlatina or measles may actually com- 
plicate diphtheria. 

VII. The Glands. — The anterior cervical glands are swollen, ten- 
der and painful. In the most severe forms periadenitis follows with 
diffuse involvement of the cellular tissue (angina Ludovici), section of 
which evacuates serum, though seldom pus. Glandular and articular 
changes are less frequent than in scarlatina. Muscular degeneration, 
interstitial infiltration, and tendency to separation of the muscle-fibers, 
are observed in the heart (myolysis or fragmentation) or even more 
clearly in the diaphragm. 

Diagnosis. — To the naked eye a thick, adherent membrane, which 
is not removable without hemorrhage and which leaves ulceration 
(Bretonneau), is sufficiently characteristic. The enlarged glands are 
of diagnostic value. A positive bacteriological diagnosis is important, in 
such cases as have actual membrane, diffuse reddening, and tonsillitis ; 
but three or four negative examinations are necessary before negative 
conclusions can certainly be drawn. The statistics of Heubner and 
of Baginsky show positive findings in from 92 to OS per cent, of cases 



170 THE SPECIFIC INFECTIONS 

in which the clinical diagnosis of diphtheria has been made. These 
figures are probably most nearly correct, although others find the diph- 
theria bacillus in a notably lower percentage. The nose, nasopharynx 
and pharynx must always be examined in sick children and also in 
adults. In suspicious cases, particularly when cultures cause consider- 
able delay, antitoxin, should be given at once. 

The health departments in our large cities provide apparatus for 
growing cultures, stations at which cultures and antitoxin may be 
obtained, and central and subsidiary laboratories for diagnosis. The 
Chicago Health Department has also a most able corps of physicians 
for free treatment, consultation and intubation. It is easy to obtain 
on sterile cotton on a probe a smear from the membrane or suspicious 
focus, to rub it on the serum without breaking its surface, and to put 
the tin box containing it in the incubator or under the axilla until the 
brood oven can be reached. In half a day characteristic cultures are 
obtained. Direct smears from the throat on a slide very often show 
the bacillus. In small places communal laboratories can easily be 
maintained, and competent young practitioners found to do this, and 
other clinical microscopy. In laryngeal diphtheria the bacillus is 
usually found on the pharynx, but not on the tonsils. Repeatedly 
negative findings are of value in the pseudodiphtheritic or diphtheroid 
pharyngitis, rhinitis, laryngitis, and bronchitis, — e. g., membranes due 
to strepto-, staphylo-, and pneumococci, aphthous growth, syphilis, 
and the colon bacillus. The scarlatinal membrane has been consid- 
ered. In Vincent's angina (q. v.), angina diphtheroides or angina 
ulceromembranosa, described by Vincent (1898), there is a whitish- 
yellow to grayish-brown membrane which may be confused with 
diphtheria and syphilis and which is caused by the symbiosis of two 
otherwise innocuous parasites; first the bacillus fusiformis (6 to 12 ji 
and staining readily with methylene blue and fuchsin), and the spiro- 
chseta darticola (twice as large, and not growing in cultures). The 
infection is usually mild and the ulcers heal slowly under chlorat. 
potash gargles or painting with pure iodine. 

Course and Prognosis. — Aside from complications, the average 
course is one week, or possibly two. It is more favorable in diph- 
theria of the tonsils and skin than in that of the nose. The prognosis 
must always be guarded, (a) Without serotherapy the danger is 
always great, since light cases may become severe or extend to the 
larynx. (6) Epidemics vary in virulence, 30 to 50 per cent, mortality 
having been observed twelve to fifteen years ago. (c) According to 
Glaeser, in the first year the mortality is 77 per cent., and sinks with 
each year until it is, at ten years, 20 to 25 per cent. ; after ten, 2 to 5 J 
per cent. ; after thirty and forty, 1 to 3 per cent, (d) Other factors are 
debility, wide extension of the infection from part to part, adenitis, 
and croup; the general diphtheritic infection or septic forms with 
hemorrhage or gangrene; heart and renal complications; rapid and 
weak or slow pulse; involvement of the brain or nerves, (e) In 946 
fatalities studied by White and Smith, about 50 per cent, died of 



DIPHTHERIA 171 

bronchopneumonia, usually after intubation or tracheotomy; 25 per 
cent, died of cardiac complications, and 25 per cent, of early severe 
toxaemia, though some succumbed to asphyxia or late paralysis. (/) 
Coincidence with other acute infections is ominous, such as measles, in 
which the exanthem may become hemorrhagic, and respiratory catarrh, 
may result in a wide Klebs-Loeffler infection, the combination being 
usually fatal; coincidence with typhoid, frequently with gangrene or 
laryngeal stenosis; and with scarlatina, summer diarrhoea, and tubercu- 
losis. The disease is less severe in conjunction with varicella and 
pertussis. Diphtheria belongs to the class of infections which are 
likely to recur. 

Treatment. — First Indication — Prophylaxis. — For the physician, 
this begins with the case in hand. Isolation must be absolute. In 
needy families the isolation hospital offers the best solution. In Bos- 
ton it has reduced the mortality of diphtheria to one-third or one- 
sixth of its former rate. All suspicious throat cases should be isolated 
pending their immediate clinical and cultural evolution. Not only 
should a sick child be isolated, but other children in the family should 
be kept from school and away from playmates. Of course, the sick 
one must be isolated until its throat gives negative cultures. The 
physician may protect himself by examining the throat through a 
piece of glass, and may avoid carrying the germs by slipping on a 
surgical gown and washing both face and hands with bichloride of 
mercury or similar solution. In fatal cases the body should be wrapped 
in a sheet saturated with bichloride, and buried privately in a tightly 
closed casket. Those exposed to the infection may receive antitoxin, 
and should gargle the throat once with \ of 1-per-cent. solution of silver 
nitrate, or often, with bichloride of mercury (5000). The clothing, 
blankets, rugs, etc., must be steamed. After convalescence, the walls 
of the room should be rubbed with bread which is then burned, the 
woodwork should be washed with 2-per-cent. lysol solution or 1-per- 
cent, bichloride of mercury and the room should be fumigated with 
formaldehyde. Under prophylaxis may be included the building up 
of the general physiological resistance and the treatment of chronic 
catarrh of the nose, throat, and bronchi. 

Second Indication — Local Treatment. — Though local treatment of 
the throat is less important than before the days of serotherapy, the 
antitoxin does not always kill the bacilli, and does not affect the asso- 
ciated streptococci. Caustics are never necessary. In children such 
mild antiseptics as 3-per-cent. boric solution and 3 to 10-per-cent. 
potassium permanganate solution, should be used lest they be swal- 
lowed. The child is held in the nurse's arms with its arms and body 
firmly wrapped in a sheet. The mouth is made to open by closing 
the nostrils, and a piece of wood or cork is inserted between the teeth. 
The throat is then swabbed. It is a harsh procedure and the effects 
are apparently more than offset by the resultant exhaustion. In adults 
1 to 1000 bichloride, 25-per-cent. hydrogen peroxide, or 1-per-cent. 
carbolic solutions, 5-per-cent. ammonium sulphocarbolate, 5-per-cent. 



172 THE SPECIFIC IXFECTIOXS 

ferric chloride or iodoform salve, may be used, or Loeffler's solution, 
which is as follows: 

Menthol 10 parts. 

Toluol 30 parts. 

Tr. ferri sesquichloridi 4 parts. 

Alcohol absoluti 60 parts. 

Loeffler's solution should be kept w T ell corked in a dark bottle. Local 
injury, such as opening up new wound surfaces for infection, must be 
avoided. In nasal irrigation the tube is held horizontally, so that 
fluid may return by the other nostril. A kettle containing a very 
weak carbolic solution should be kept steaming in the room. 

Third Indication — Serotherapy. — Gscheidlen and Traube showed 
that the blood possessed antibacterial action, both within and with- 
out the body, and immunity was produced by Behring against anthrax 
and by Bouchard against the Bacillus pyocyaneus. Behring demon- 
strated also that the serum in diphtheria and tetanus could overcome 
bacteria without destroying them. In 1888, Richet and Hericourt 
made animals immune to the streptococcus, and Behring and Kitasato 
produced immunity to tetanus. Behring (1890) borrowed Ehrlich's 
results with ricin and abrin to establish the units of immunization, 
and (1893) used the diphtheria antitoxin on diphtheria patients. The 
method of action of an antitoxin is vital or active (Buchner, Roux, 
Martin) though some, (Behring and Kitasato) consider that it is 
chemical or passive. 

1. Technique. — A syringe with an asbestos plunger should be 
used. The syringe need not be boiled each time, but should be cleaned 
after each injection with water until the serum is washed out; it 
should then be washed with carbolic acid or alcohol, which should 
be thoroughly removed each time lest it coagulate the antitoxin at 
the next injection. The needle must be boiled each time. With ordi- 
nary surgical antisepsis, inject the antitoxin into the subcutaneous 
tissue of the thigh in adults, and into the interscapular region in chil- 
dren. In very severe infections, intravenous injections should be em- 
ployed as results may be thus obtained eight hours earlier. The unit 
is 1 c.c., which counteracts ten times the minimum dose of diphtheria 
poison fatal to a 300 gm. guinea-pig. 

2. The dosage is rather empirical, depending on the localization, 
age, and severity of the disease and the effects produced. The usual 
classification is as follows: (a) Single: 600 units, used in cases under 
two years, without croup; for immunization, a somewhat smaller 
dose is required than for cure (200 to 500 c.c). (b) Double: 1,000 
units, in children under two years when croup, fetor or necrosis occur; 
in older children with simple symptoms, (c) Triple: 1,500 units, in 
severer cases. On the whole, dosage is governed by results {v. i.). 
After administration the discharge should lessen, the membrane should 
exfoliate, the fever should fall, and toxaemia decrease. At least twice 
as much antitoxin is necessary for cure as for immunization. After 



DIPHTHERIA 173 

eight hours, three times as much is necessary as at the beginning; 
after twenty-four to thirty-six hours, eight times as much. As we 
cannot measure the toxins, so we cannot exactly specify regarding the 
antitoxin dose. Personally, the author prefers an initial dosage of 
3,000 to 5,000 units to insure results and to avoid delay and frequent 
repetition. The decreased bulk of present preparations also allows 
a larger dosage. In severe cases, twice the above amount should be 
given. McCallum, above all others, has emphasized the importance 
of full doses, and he speaks, and with reason, of doses of 10,000, 30,000, 
or even 50,000 units in desperate cases, because results must be pro- 
duced. In a recent article, H. A. Hare states that antitoxin dosage 
is not measured by units and that children require as large doses as 
adults. He cites Sutherlin as giving a total of 498,000 units in one case ! 
3. Effects. — (a) The local changes are lessened, the mucosa becomes 
redder, and the membrane more yellow and it exfoliates in from one- 
half to two or three days, with decrease in glandular swelling. Exten- 
sion afterward is rare, (b) The fever falls by crisis or by lysis, unless 
there are complications. A temporary rise in temperature sometimes 
occurs. Antitoxin is given until the fever falls, (c) The pulse is les- 
sened, and hyperleukocytosis is decreased. Light cases rarely become 
severe, and nonseptic rarely become septic, unless there is coexisting 
tuberculosis, syphilis, etc. The kidneys are never injured. The author 
believes that paralysis and heart failure are less frequent when the 
administration of the antitoxin is prompt. Both of these complica- 
tions are thought to occur in the same proportion as in pre-serum 
days. But even if their percentage is not absolutely reduced, many 
patients now live who would previously have died before developing 
paralysis, (d) The mortality is reduced from 41 (or 43 to 46 per cent.) 
to 15 per cent. (Siegert's collection 42,000 cases) ; 10 per cent. (Wenner, 
9.8 per cent., 132,500 cases, American cities) ; or 6.7 per cent. (Chicago 
Health Department Report). London statistics give a reduction of 
one-third in the general morality and one-half in tracheotomy (60 
per cent, morality reduced to 32 or 25 per cent.). The fatal cases 
and severe complications are lessened in direct ratio as the antitoxin 
is given early ; if on first day of disease, ; second day, 2 per cent. ; 
third day, 8 to 10 per cent. ; fourth day, 14 per cent. Failure to use 
antitoxin is criminal neglect; 50 per cent, of croup cases regress with 
the use of antitoxin, and heart lesions are reduced 50 per cent, in fatal 
cases. (5) Antitoxin is a prophylactic, and should be given in special 
instances; e. g., to weak or very young children (in smaller doses). 
It protects for two or three weeks in all but 0.7 per cent, of 1,000 cases 
(Zuppinger). (6) The sequels are: (i) Abscess formation; (ii) exan- 
themata, which are local (on the fourth or fifth day) or general (in one 
to two weeks), are due to individual peculiarity or some unknown 
element in the antitoxin, and appear as urticaria, morbilliform, scar- 
latiniform, or petechial eruptions; antitoxin rashes occur in 33 per 
cent, of the cases; and are said to be decreased by the administration 
of potassium acetate (gr. x to xxx), combined with free catharsis 



174 THE SPECIFIC INFECTIONS 

(Roehr); (iii) nephritis, which is always due to the diphtheria itself; 
(iv) sudden death which results from vomiting into the larynx, 
shock, lymphatic diathesis, and from other disease; sudden death is 
exceedingly rare; (v) tetanus has been inoculated. In a few cases 
where antitoxin was injected for prophylaxis, the author has seen ex- 
tremely severe symptoms; pallor alternating with flushing, chills, 
fever, renal suppression, oedema of the skin and pharynx and very 
severe cardiac weakness; these cases to a certainty had no diphtheria, 
for throat cultures were first taken; the statement, therefore, that 
antitoxin never injures does not hold for all prophylactic doses. 

Fourth Indication. — General and Symptomatic Treatment. — A rich 
fluid diet of milk, eggs, peptonoids, with tonics, cinchona, wine, etc. 
is given. In marked dysphagia rectal feeding is indicated. Forced 
feeding by the stomach tube or nasal catheter is dangerous because 
injury to the throat is likely. 

Sepsis. — Concentrated diet by mouth and rectum, alcohol ad lib- 
itum, oxygen, saline infusions or enemata, strychnine and iron, and 
Marmoreck's antistreptococcic serum should be given; but all meas- 
ures are usually of no avail if 4,000 units (Baginsky) or tens of 
thousands of units do not give relief. Crede's collargol is given intra- 
venously in severe cases; Netter, in 586 cases, found that it reduced 
the death rate by 8 to 20 per cent. 

Paralyses. — General stimulation and alimentation are indicated; 
electricity is of little or no avail; massage, baths and strychnine are 
useful in the later stages. 

Heart Failure. — The ice-bag is indicated for stormy heart action; 
ether, iron, valerian, oxygen, alcohol, digitalis, strophanthus, coffee, 
aromatic wines, camphor and strychnine should be given. For severe 
abdominal pain and vomiting, usually an evidence of cardiac failure, 
the above remedies, and champagne with menthol and carbolic acid, 
are indicated. The heart must be watched far into apparently com- 
plete convalescence. 

Nephritis. — Nephritis cannot be prevented. Alcohol, tincture of 
ferric chloride, beef tea and eggs are to be avoided; vichy, cardiants, 
milk diet, baths, laxatives, and care of the skin are advisable. 

Local Diphtheria. — Two per cent, nitrate of silver in balsam of 
Peru affords relief in vaginitis; ice applications, atropia, and silver 
in ophthalmia; over inflamed glands, a 10 per cent, ichthyol salve 
may be applied; local diphtheria necessitates antitoxin, independently 
of its location. 

Croup. — Mercurial inunctions are given, together with steam sprays 
or tents and ice locally applied; for emergencies, the hot water may 
be turned on in the bath-room, after closing the door (Jacobi); or 
the child may be held over a pail of water into which live coals are 
thrown; emetics may be administered, with which wine (Strieker) is 
given because emetics often fail in carbon-dioxide narcosis; retrac- 
tion of the chest walls, suffocation, cyanosis, and cold extremities, 
necessitate intubation or tracheotomy. 



INFLUENZA {LA GRIPPE) 175 

O'Dwyer's Intubation. — Advantages. — It is bloodless, is shorter, 
easier, and quicker than tracheotomy; there is less wound infection, 
and it is less objectionable to the family. 

Disadvantages. — Membrane may rise beneath the tube, and trach- 
eotomy may therefore be necessary after intubation. The tube may 
sometimes produce trauma, false passages, necrosis, ulcers, perichon- 
dritis and stricture. The tube is usually replaced two, three, or four 
times, and rarely need remain more than five or six days when the 
serum is used. It is removed by the extubator, by pressure, or by a 
string, which is necessary in private practice. Size of the tube : 5 to 6 
millimeters, one to two years; 6 to 7 millimeters, two to four years; 7 
to 8 millimeters, four to six years; 8 to 9 millimeters, six to eight years. 

Tracheotomy. — Tracheotomy is indicated when the heart is weak 
or when great asphyxia, much secretion, or gangrenous, diffuse, or 
septic infiltration or oedema of the lungs exist. In the after-treatment, 
the patient requires a moist atmosphere, and cleaning of the tracheo- 
tomy tube every second day, is important. The tube should not be 
permanently removed until all stenotic symptoms and all plaques 
disappear. In cases treated by serotherapy, this may be done on the 
fourth day as against the sixth or seventh in cases treated before anti- 
toxin was introduced. The prognosis of tracheotomy depends upon 
possible coincident wound-infection with erysipelas or diphtheria, 
phlegmon, thrombophlebitis, mediastinal suppuration, ulceration of 
trachea, inhalation pneumonia, cardiac collapse, and nephritis. Rapid 
rise of temperature is ominous. Antitoxin has reduced the mortality 
from 66 per cent, to 35 per cent, (or 25 per cent.). 

CEREBROSPINAL FEVER. 

Cerebrospinal fever (epidemic meningitis), is an independent in- 
fection, but will be considered under diseases of the meninges, with 
the tuberculous and suppurative forms. 

INFLUENZA (LA GRIPPE). 

Definition. — A specific infective disease, caused by the Bacillus 
influenzae, propagated by direct human intercourse but also by means 
of f omites ; endemic over the entire world and almost yearly epidemic 
somewhere, characterized by its unparalleled rapidity in extension, 
the large number of people attacked, its protean symptomatology 
and its particular affinity for the respiratory tract. 

Varieties. — (1) Influenza vera, (a) pandemic; (b) endemic or epi- 
demic, due to Pfeiffer's bacillus. (2) Influenza notha s. nostras, 
pseudogrippe, catarrhal fever of unknown bacteriology. 

Pandemics originate in Asiatic Russia. No other pandemic has 
ever been so widely distributed as influenza, which spreads very 
rapidly but not faster than the fastest trains and steamers. The 



176 THE SPECIFIC INFECTIONS 

rapidity of its dissemination is due (1) to the enormous virulence 
of the virus; (2) to the ease with which the germ is spread; (3) to 
the universal susceptibility; (4) to the short incubation period (one 
to three days), and (5) to the fact that a great number of mod- 
erately sick individuals frequent cars, conveyances, churches, schools, 
and places of business. Epidemics develop gradually, usually follow- 
ing pandemics; they occur every few years (pandemics are separated 
by decades), last one to two months, are less severe because of les- 
sened virulence of the virus and increasing immunity. According to 
Hirsch, the first epidemic occurred in 1173. The first pandemic 
seems to have been in 1510. 

Etiology. — Though no age confers immunity, most cases occur be- 
tween the twentieth and fortieth years and especially in robust indi- 
viduals. Physicians are very often attacked. The immunity usually 
conferred by one attack is less enduring and absolute than in small- 
pox, and other infectious diseases. 

Bacteriology. — The organism discovered by PfeifTer (1891-2) is the 
smallest bacillus which has been cultivated. Its ends are rounded 
and it resembles a diplococcus when two bacilli lie end to end. It 
has no capsule, is non-motile, it lies free in the sputum in the early 
stages and later is found in the leukocytes, but often disappears early 
from the sputum. The bacilli lie in lines "like schools of fish" (Finck- 
ler). Ten minutes are necessary for staining with carbol fuchsin. 
The bacillus is aerobic, short-lived, and very susceptible to drying. 
Culturally it grows characteristically on blood-serum as closely com- 
pressed yet discrete colonies, clear as water, and almost microscopic 
in size; it grows at body temperature and is easily overgrown by 
saprophytes. The germ has also been found in rare instances in the 
blood, in pneumonic and encephalitic foci, in the peritoneum, spinal 
fluid, gall-bladder, heart, spleen and kidney, and possesses rather 
marked pyogenic characters; it is often associated with the pneumo- 
coccus and streptococcus. Its atrium is probably through the upper 
respiratory tract although there are instances of primary pneumonia. 
The nervous and alimentary types are probably likewise explained. 

Symptoms. — It is sometimes said that there is no uniform clinical 
picture of influenza and certainly there is scarcely an acute infection 
with such varied grouping of symptoms and such varied sequels and 
complications. 

After a short incubation, which never exceeds one to three days, 
the grippe begins suddenly with chill and fever, headache, usually 
frontal, great anorexia and depression, pains in the back and legs, 
respiratory catarrh, which is frequently followed by capillary bron- 
chitis or pneumonia in children or the aged, and intense nervous and 
sometimes digestive symptoms. Lichtenstern classifies influenza as 
follows: 

(A). Purely Toxic Type. — (1) Simple influenzal fever; fever with 
its symptoms, headache, etc. (2) Nervous form; fever, pains in the 
back, legs and head, neuralgias, and prostration. 



INFLUENZA {LA GRIPPE) 177 

(B). Toxic Inflammatory Type. — (1) Respiratory catarrh of the 
nose, throat, larynx, trachea and bronchi. Respiratory symptoms 
are absent only in 25 per cent, of cases, a fact not recognized before 
1889-1890. (2) Gastro-intestinal catarrh, coated tongue, anorexia, 
vomiting and diarrhoea. 

The duration is short (one to three days) and the diagnosis is usually 
easy without the detection of the bacillus. Recurrences are frequent. 
Nervous symptoms in the primary attack may be followed by respir- 
atory complications in the recurrence, or, more frequently, an initial 
respiratory catarrh is seen with nervous manifestations in the recrudes- 
cence. In rare instances influenza may cause chronic symptoms, 
chiefly respiratory. Convalescence is marked by great nervous de- 
pression, neuralgias, and tardy return of vigor. 

Special Symptoms. — 1. Fever. — The rise is usually sudden to 
103° or 104°; but on exceptional occasions it rises gradually. It is 
entirely atypical. Remittent fever is more common than continuous 
fever, which may suggest typhoid. It is occasionally intermittent, 
resembling malaria. Hyperpyrexia is observed particularly in en- 
cephalitis grippalis, but again some of these cases and certain nervous 
forms are afebrile (Eichhorst). The typus .inversus has been noted 
(Pribram). The fever lasts from one to three or four days, it is often 
shorter than the other symptoms and rarely lasts a week. Some- 
times the fever returns after two or three days, constituting a recur- 
rence or relapse. Fever may last longer as a result of complications. 
Often there is a remarkable loss in weight. 

2. Nervous System. — The nervous system is almost always in- 
volved and is second in importance only to the respiratory tract. The 
most frequent disturbances are functional and psychical, but gross 
anatomical lesions are sometimes found. Headache is observed in 
nearly 100 per cent, of the cases. It is especially frontal and often 
very severe. Influenza comatosa results from very acute intoxication, 
which may cause epileptiform seizures, tremors, or severe delirium. 
The post-influenzal psychoses, acute and chronic, are due to cerebral 
toxaemia or exhaustion and are observed five to eight times as fre- 
quently as in any other acute disease. An hereditary tendency is 
observed in 62 per cent., and most cases are seen in the young. They 
may occur from the initial intoxication but usually follow the attack. 
The majority are of the hypochondriacal type (exhaustion psychoses), 
but mania is sometimes seen. Suicides were increased 25 per cent, 
in Paris during the last pandemic. In encephalitis grippalis, of which 
twelve cases are recorded, there are acute hemorrhagic foci of inflam- 
mation (Virchow, Senator, Furbringer, Konigsdorf, Schmidt, Oppen- 
heim), which are usually discrete (sometimes confluent) and multiple; 
they almost always occur in the gray substance of the cortex or ganglia 
and vary in size from the "flea-bite" spots of inflammatory hemor- 
rhage with surrounding softening to the size of a cherry or pigeon's 
egg. The inflammation is due to embolism by the Bacillus influenzae 
(Pfuhl and Nauwerk) or to encephalitis suppurativa, which in turn is 

12 



178 THE SPECIFIC INFECTIONS 

either primary or secondary to foci in the nose, ear, and lung. Some- 
times concomitant venous thrombosis, hemorrhage, pachy- or lepto- 
meningitis occur. Cortical focal symptoms (mono- and hemiplegia) 
or a sudden apoplectiform onset may mark the process, or there may 
be diffuse cerebral symptoms at the beginning or acme of the disease, 
without definite focal localization. Encephalitis is usually fatal but 
recovery is recorded. Meningitis grippalis generally develops early. 
The virus reaches the brain by the blood stream or by contiguity 
through the basis cranii. In localization it is basal or cortical. Lum- 
bar puncture may show the grippal bacillus, which may distinguish 
this from other forms of meningitis and from toxsemia (pseudomenin- 
gitis or meningismus). Mya (1904) reported three cases of suppura- 
tive meningitis in which recovery occurred; the bacillus was found 
by lumbar puncture. Spinal complications, such as transverse mye- 
litis, hemorrhagic disseminated myelitis, Landry's paralysis, and acute 
poliomyelitis, have been observed clinically though investigated but 
little pathologically. Neuritis, local or general, is usually post-influ- 
enzal; nuclear (spinal) changes are sometimes suggested. Pains are 
frequent in the back, legs and joints; neuralgia may affect any 
nerve, but most often the fifth, sciatic, and intercostals; neurasthenia, 
which is often hypochondriacal, and hysteria may be observed as 
sequels. 

3. The Respiratory Tract. — This is the entrance for the bacillus 
and is involved in 75 per cent, of cases, either entirely or in one part, 
as is the case in such inflammations as coryza and bronchitis. 

Epistaxis is quite uncommon, though coryza, with reddening of 
the eyes, is seen in 70 per cent, of cases, and may possibly be accom- 
panied by involvement of the frontal or other sinuses, or even em- 
pyema or neuralgia of the same. The bacillus may be found in the 
conjunctiva. 

Angina is seen in 33 per cent, and tonsillitis in 60 per cent, of cases. 

Laryngitis (6 to 16 per cent.) occurs with hoarseness. Fibrinous 
deposit or submucous abscess has occurred. 

Tracheitis (50 to 80 per cent.) causes pain, tenderness and severe 
paroxysmal cough, induced by irritation at the bifurcation. 

Bronchitis is either diffuse, developing anteriorly as well as poste- 
riorly (Kundrat), or more characteristically, occurs over one lung or 
one lobe. At autopsy are found great congestion (which is the prime 
lesion according to Klebs), a tendency to extension, hemorrhage, 
round-cell infiltration into the mucosa, and exudation and throm- 
bosis in the smaller vessels, which causes necrosis of the mucosa. 
The sputum, according to Pfeiffer, is characteristically nummular and 
greenish-yellow. It is often blood-stained, contains the bacillus, is 
viscid and is often abundant. Rales are most often found above the 
liver and near the lingual lobe. We also may observe dyspnoea, which 
is nervous (Graves) or congestive (Biermer) in origin, without appro- 
priate physical findings. Cyanosis may develop, and is particularly 
dangerous in the young, aged and decrepit. 



INFLUENZA {LA GRIPPE) 179 

Acute bronchiectasis is not uncommon, but usually escapes clin- 
ical recognition. 

Influenzal pneumonia occurs in from 5 to 8 per cent, of the cases 
and is the most important complication. PfeifTer's bacillus is 
its most frequent cause, according to Leichenstern and Wasser- 
mann. The pneumococcus, streptococcus, and staphylococcus, alone 
or combined with the Bacillus influenzae, are the cause of some 
cases. 

Genuine lobar pneumonia undoubtedly occurs, and a grippe epi- 
demic may double the number of lobar pneumonia cases. When it 
complicates grippe it is said to be less completely lobar and less 
clearly granular. 

Influenzal pneumonia, strictly speaking, is exclusively catarrhal 
(Pfeiffer, Back, Wassermann), and shows no fibrinous exudation or 
granulations, but merely infiltration of cells, which commences about 
the bronchi as multiple distinct foci with normal lung between them; 
(the lobular foci sometimes fuse into secondary lobar pneumonia), 
It often causes minute abscesses. There is another type like the 
"acute lobar desquamative pneumonia" of Buhl, and still another, 
the "acute primary streptococcus pneumonia" of Finkler, which is 
lobular and catarrhal. Uncertainty as to the exact type may exist, 
but as Ziegler, Sahli, Kundrat and Weichselbaum have shown, 
mixed infection is of great importance. Clinically, the pneumonia 
is usually atypical and begins insidiously without a chill, but with 
increase of the prior cough and dyspnoea. It develops during or after 
the influenzal attack, although pneumonia may be the first sign of 
influenzal infection. Its symptoms are more pronounced than its 
physical signs, and the disproportionate cyanosis and dyspnoea some- 
times suggest miliary tuberculosis. Foci of dulness may be found 
but distinct bronchial breathing is rare; bronchophony is a much 
more reliable symptom. The heart is often weak and a peculiar 
redness of the face and head, profuse sweats at the beginning, and 
characteristic paroxysmal coughing are symptoms not seen in ordi- 
nary pneumonia. The foci may be bilateral or multiple (60 per cent, 
of the cases) and the apices are involved very frequently. The symp- 
toms and signs may recur or intermit as the consolidation wanders 
from place to place. The sputum is purulent or bloody, but the type 
of pneumonia is not determined either from the sputum or from its 
bacteriology. Influenzal pneumonia may result: (1) In solution by 
lysis; (2) in death in the first stage of congestion from oedema pul- 
monum; the patient may die later, gray hepatization having set in 
within three days; the mortality is 20 to 30 per cent.; (3) in chronic 
influenza pneumonia, with hectic fever and suppuration; e.g., in an 
upper lobe (Graves, 1837); it may simulate tuberculosis; during a 
grippal epidemic, an increased mortality from tuberculosis is noticed ; 
(4) in abscess or gangrene of lung . 

Pleurisy may follow pulmonary lesions or even the bronchitis 
(Kundrat). Primary pleurisy occurs in 27 per cent. (12 to 33 per 



180 THE SPECIFIC INFECTIONS 

cent.) of the fatal cases of influenza. It may begin early and its symp- 
toms are frequently severe and protracted. 

4. Circulation. — The heart-muscle is directly injured, especially 
in its nervous apparatus. The lesser circulation is most involved. 
Weakness of contraction, syncope, even death, may occur during 
convalescence, especially when there are preexisting fatty, valvular, 
or arteriosclerotic changes. The pulse is labile, often arrhythmic or 
dicrotic (Pribram); it may be rapid, and out of proportion to 
the fever; cyanosis, dyspnoea and bronchiolitis are frequent in such 
cases. A slow pulse is very frequent (45 to 50 per cent.) in severer 
types and is caused by toxemic stimulation of the vagus. Acute endo- 
carditis resulting from mixed infection sometimes follows suppurat- 
ing foci in the lungs; three cases are recorded in which the influenza 
bacillus was found. Pericarditis is a sequence of other lung or heart 
disease. Acute phlebitis is seen mostly in severe cases, when the 
heart is weak (cardiac type), and occurs most frequently in the upper 
extremities. Arteritis is rare, is embolic or primary, occurs mostly 
in the popliteal vessels, and may end in gangrene. The existence of 
leukocytosis is denied by some writers; it occurs in not more than a 
third of the cases. Blood disintegration and hemorrhages into the 
skin, serous and mucous membranes, usually indicate severe intoxica- 
tion. 

5. Alimentary Tract. — Digestive symptoms are not especially im- 
portant. The tongue is coated but rarely dry or typhoidal. Fetor 
ex ore and vomiting (34 per cent.) which is sometimes bilious and 
persistent, and grippal hyperesthesia of the stomach may be observed. 
Constipation is more frequent than diarrhoea. Typhoidal symptoms 
may occur (see Differentiation). There are the usual febrile degen- 
erative changes in the liver. Icterus is rare (2 per cent.). The spleen 
is enlarged clinically in but 15 per cent, of cases. 

6. Genito-Urinary Tract. — Albuminuria (under 10 per cent.) may 
result from toxaemia or stasis. Altered red blood-cells in the urine 
are rather frequent. Acute glomerulonephritis occurs in 1 per cent, 
of cases. Diabetes mellitus is said to have followed influenza; if 
influenza complicates an old diabetes, the prognosis is doubtful or 
unfavorable. Hay em found urobilinuria almost constantly. Senator 
noted the frequent occurrence of the diazo reaction and of indicanuria. 
Cystitis, hematuria, menorrhagia, abortion and orchitis are but oc- 
casional complications. 

7. Skin, Muscles, Joints. — Urticaria, herpes (5 to 25 per cent, of 
cases), redness and hyperidrosis (vasomotor paresis), miliaria, ery- 
thema nodosum or multiforme, scarlatiniform or morbilliform erup- 
tions on the face or chest, purpura, erysipelas, and pemphigus may 
be noted. Skin eruptions occur in 16 per cent, of the cases. Poly- 
synovitis (rheumatoid form 7 per cent.), pyarthrosis or myositis are 
not common; bone troubles are not important and are infrequent. 

Eye involvement (7 per cent.), conjunctivitis, keratitis, herpes, pain 
in the eye-ball, swelling of the lids, and otitis media (30 to 40 per 



INFLUENZA {LA GRIPPE) 181 

cent.), which is usually purulent, and often hemorrhagic, are due to 
the pyogenic cocci, pneumococci and the influenza bacillus. 

Diagnosis. — At the time of an epidemic the diagnosis is usually 
easy. Respiratory catarrh, headache, pains in the joints and back, 
nervous depression and tardy convalescence are significant. The 
diagnosis of the toxic, nervous and alimentary forms is more difficult 
and many errors may be made. The importance of bacteriological 
diagnosis has been over-rated, but positive results are decisive. 

Differentiation. — Typhoid Fever. — The diseases may be confused 
when atypical severe influenza begins with gradual, step-like rise of 
the fever and typhoid symptoms, such as tympany, enteritis, colic, 
peritoneal manifestations, intestinal hemorrhage, swelling of the spleen, 
and roseolse. At autopsy, swelling and even ulceration of the stomach 
mucosa and Peyer's patches occur (Jiirgens). However, coryza, con- 
junctivitis, the existence of an epidemic and early catarrhal symptoms, 
indicate influenza, and the serum test and other cardinal typhoid find- 
ings (q.v.) decide the diagnosis. 

Simple Coryza, Bronchitis, etc. — These are distinguished from true 
influenza by the sudden rise of fever in influenza, its nervous mani- 
festations, pains in the head, bacteriology, spleen and exanthems. 
Lord found the bacillus of Pfeiffer in 30 per cent, of bronchitis cases 
in Boston, in which there was no suspicion of influenza. 

Measles. — The early diffuse respiratory catarrh in each disease may 
cause confusion, and doubts may be increased by measles-like erup- 
tions in influenza, but the typical measles fever curve (the fever rising 
again, after the prodromes, with the exanthem), and Koplik's spots, 
determine the diagnosis on the third or fourth day. 

Miliary Tuberculosis. — This is suggested only in severe respiratory 
types; the history is usually distinctive. 

Meningitis. — Influenza may masquerade as a pseudomeningitis, but 
focal signs are usually absent and doubts are settled by continued 
watching and lumbar puncture. 

Apoplexy, the acute psychoses and acute poisoning are rarely simu- 
lated by influenza. 

Prognosis. — (1) The morbidity is enormous, reaching 50 or even 
75 per cent, of the population (pandemic of 1889-1890). (2) The mor- 
tality is i 6 o to 1 per cent., but statistics are unreliable since the diag- 
nosis of influenza is often carelessly made. It is certain that influenza 
increases the total number of deaths from pneumonia and tuberculosis, 
especially in the weak and aged. In some cases the course is chronic, 
the bacillus being found in the sputum for weeks or months, especially 
in tuberculous subjects, who are remarkably susceptible. 

Treatment. — There is scarcely any prophylaxis except that persons 
should avoid crowds. Isolation should be practised in asylums, hos- 
pitals and prisons. Quinine is thought valuable, but is very uncertain. 
Gargles and nasal douches may possibly prevent infection and are 
distinctly indicated in grippal patients. There is no specific treatment 
and symptoms must be met as they arise. In every case, influenza 



182 THE SPECIFIC IXFECTIOXS 

should be treated as a serious disease and complications should be 
avoided by means of rest in bed and restricted diet. The treatment 

is much like that of a severe cold. 

1. Pain. — At the onset, Dover's powder and antipyrin aa grains 
x, at once, are given for pain. Antipyrin has been used to excess, but 
is superior to acetanilid and phenacetin. If these measures do not 
relieve the pain, the salicylates should be used as they are in rheu- 
matism. Cold baths for high fever are poorly tolerated by the patient. 

2. Catarrhal Symptoms. — In conjunctivitis, boric acid solution is 
excellent: in coryza, douches with Dobelle's solution, tincture of 
belladonna and of aconite in two- and one-drop doses, respectively, 
should be used every half hour for about three hours, and the alkaloid 
cocaine gr. j to albolene §j should be used locally; in pharyngitis, 
silver nitrate (20 per cent.} should be applied once or twice; in ton- 
sillitis, nitrate of silver should be introduced into the follicles which 
are first opened and touched with Dobelle's solution: for bronchitis 
(q. v.), codeine or morphine is indicated; for enteritis, bismuth and 
paregoric aa 5j should be given after each bowel movement. 

3. Severe Nervous Symptoms. — These are somewhat relieved by 
warm baths. Neuralgia necessitates the use of antipyrin, gelsemium, 
quinine, camphor, iron and arsenic. Headache is treated as it is in 
typhoid; it is increased by alcohol. 

4. Heart. — The heart may require strychnine. 

5. Convalescence. — Care in convalescence is important; cases of 
chronic tuberculosis or bronchitis require high altitudes. 



PERTUSSIS (WHOOPING-COUGH). 

Definition. — A specific, frequently epidemic, infection of the upper 
air-passages, occurring chieflv in children, and characterized bv a 
cyclic course and a severe convulsive cough, which ends in a long- 
drawn, spasmodic inspiration or whoop. 

History. — Pertussis was described bv Ballonius (1578) and Willis 
(1674 . 

Etiology. — [a) Age. — It usually occurs in children and is most 
frequent at the fourth year seven months to seven years). It is ex- 
tremely infrequent after the twentieth year, though cases do occur in 
middle and advanced life. 

(b) Sex. — Sixty-six per cent, of cases occur in girls, females being 
more inclined to spasmodic diseases, (c) Anaemia and respiratory 
catarrh are predisposing factors, [d) Most cases occur in March and 
April. 

Pertussis is clearly an infection, since (1) the disease is directly 
infective in all stages; (2) Koplik, Afianassiew and Hensel have de- 
scribed a facultatively aerobic bacillus which has small rounded ends, 
is but little larger than the influenza bacillus, and which occurs in 
clumps: (3) the disease may occur in epidemics, which develop from 



PERTUSSIS {WHOOPING COUGH) 183 

sporadic cases; (4) one attack confers almost absolute immunity. 
Incubation lasts from two to five to eight days. 

Symptoms. — 1. Stage of Prodromes. — The stadium prodromorum 
s. catarrhale is characterized by headache, backache, photophobia, 
conjunctivitis, coryza, sneezing, angina, and by a cough which becomes 
dryer and harder toward the end of this stage. In a few cases there 
is moderate fever. The digestive tract is usually intact. This stage 
averages one week (one-half to two weeks), but is often shorter when 
marked epidemics prevail. 

2. Convulsive Stage. — The stadium convulsivum s. spasmodicum 
dates from the first "whoop." The fever (aside from complications) 
ceases with the onset of this stage. The seizures are paroxysmal, con- 
vulsive, and are accompanied by dyspnoea and vomiting. As a rule 
the child is well except for the paroxysm, which has for an aura, tick- 
ling in the larynx or back of the sternum, thoracic constriction, vertigo, 
or a creeping sensation, when the child braces himself, and terrified, 
runs for support. Then the explosion comes in the form of three to ten 
or more short expiratory coughs following in rapid succession until 
the breath is lost, when the "whoop" is heard as a long, rapid, deep, 
sharp, singing or whistling inspiration. Then a thin, tenacious and 
sometimes blood-tinged mucus is expectorated and vomiting consti- 
tutes the crisis of the paroxysm. There may be apncea, great cyanosis, 
and usually diminution or suppression of the vesicular murmur. 
One to two minutes elapse between expiration and inspiration, and 
inspiratory and expiratory spasms or generalized convulsions may 
develop. The eyes are injected, the nose runs, the face is like that of 
an epileptic, the jugular veins are large and the skin is clammy. In- 
voluntary evacuations occur; the pulse is small; ecchymoses sometimes 
occur in the conjunctivae, scleras, neck or face. After the attack, con- 
sciousness returns, respiration is fast, and there is fatigue, stupor, 
sweating, and pain in the abdominal or other muscles from the strain 
of coughing or occasionally from actual muscle rupture. The attacks 
occur largely at night, but especially toward morning. In the free 
interval there may be euphoria or great depression, stomach disturb- 
ance, anorexia, inanition, or diarrhoea. The urine has a gravity of 
1,022 to 1,032, and may be pale and contain much uric acid. The 
laryngoscope sometimes reveals laryngeal or tracheal catarrh. Leuko- 
cytosis is observed early in the disease, is unusually marked, and the 
increase is chiefly in the lymphocytes (Meunier); Frank S. Churchill 
states that lymphocytosis occurs in 85 per cent, of cases, and in 90 per 
cent, during the catarrhal stage; it also occurs in those diseases which 
require differentiation from pertussis. The number of the attacks 
averages about twenty; this may be increased by excessive or 
rapid eating and drinking, by nasal or psychical irritation, and by 
respiratory efforts, such as weeping. The average is lower in a warm 
climate. 

3. Stage of Decline. — -The stadium decrementi usually comes after 
three or four weeks, but may require months. The attacks become 



184 THE SPECIFIC INFECTIONS 

less frequent, and the appetite returns. This stage is longer in propor- 
tion as the case is mild. Its complications make it the most dangerous 
stage. 

Course. — The course lasts one week for the incubation, one to two 
weeks for the catarrhal stage, three to six weeks for the spasmodic, 
and three weeks for the decline. It is modified by the following com- 
plications: 

Complications. — 1. Increase or Extension of the Usual Symptoms. 
— Catarrhal inflammation is common in the initial stage, — stomatitis, 
laryngitis, catarrhal diarrhoea (10 per cent.), and otitis media (10 per 
cent.). Bronchitis (bronchiolitis) is not common in the spasmodic 
stage. It may occur with fever, a pulse of 120 to 150, respirations of 
30 to 50, irregularity of breathing, many rales, cyanosis and atelec- 
tasis. Bronchopneumonia is the most frequent and severe complica- 
tion, occurring particularly in rhachitic children between the third 
and fifth years and is most ominous in younger subjects, especially 
those under the third year. It occurs most often in the convulsive 
period. The mortality is great, sometimes 20 to 25 per cent, of cases. 
The onset is gradual with fever of 100° to 102°, a pulse of 130 to 160, 
respirations of 30 to 80, with cyanosis and dyspnoea. An almost abso- 
lutely bad prognosis must be given in the very young. Sometimes 
the pneumonia greatly lessens or entirely prevents the spasms (Trous- 
seau). Lobar pneumonia is much rarer. Exudative pleurisy is a rare 
but very severe complication, and is seen almost exclusively in older 
children or adults. Endocarditis, pericarditis, meningitis and nephritis 
are very infrequent. Spasm of the glottis rarely occurs in children be- 
fore the fourth year and is mostly seen in those who are nervous or 
scrofulous. Its incidence is largely nocturnal, and it may cause death 
from asphyxia even in the lightest cases. Convulsions, especially in 
nervous and hydrocephalic children, may occur at any time, but are 
most frequent at the height of the apncea, at the time of first teething, 
and in the second to fifth week of the disease. They are of the carpo- 
pedal type. The eyes are rolled upward and outward, the pupils are 
dilated, and coma follows the dyspnoea. 

IT. Mechanical Complications. — Hemorrhages may occur into the 
skin, conjunctiva?, nose (relieving the cerebral congestion following 
the cough), ears and throat. Hemorrhage may occur in the brain, 
resulting fatally, or causing spastic paraplegia. Detachment of the 
retina, because of hemorrhage, and extravasation of blood into the 
lungs, stomach, and intestine, are rare. There may be wdema of the 
eye-lids, anasarca, rupture of the tympanum, or rupture of the frenu- 
lum of the tongue, the ulceration of which is almost constant. Vomit- 
ing occurs at the end of the paroxysm as a mechanical crisis to the 
attack and is so constant that the disease was once thought to origi- 
nate in the stomach. The development of chronic gastro-intestinal 
catarrh is infrequently promoted by stasis. Other mechanical compli- 
cations are cardiac dilatation, pulmonary emphysema (less often 
interstitial than alveolar), bronchiectasis, pneumothorax, involuntary 



PERTUSSIS {WHOOPING COUGH) 185 

evacuations, prolapse of the rectum or uterus, aneurysm, muscular 
ruptures, hernias, rib fracture, and spinal deformity. 

III. Toxaemia. — Marked toxaemia is rare. Parenchymatous de- 
generations are found in the fatal cases. Nephritis is not common. 

Sequels. — The hysterical coughing and spasm which sometimes fol- 
low pertussis may very closely resemble it; rhachitis is sometimes a 
sequel ; tuberculosis may involve the lungs or peritoneal or mediastinal 
lymph glands, and this sometimes produces retrosternal dulness; it 
occurs especially after pertussis with measles, both of which infections 
predispose to tuberculosis. Preexisting tuberculosis renders the prog- 
nosis of whooping-cough very unfavorable. It develops in the third 
stadium and in most cases between the sixth and tenth years of age. 
Landry's ascending paralysis has been observed. The heart-muscle 
may suffer permanent weakness. 

Diagnosis.— Diagnosis is easily made (1) by the definite stages of 
the disease; (2) by the presence of an epidemic; (3) by the absolutely 
characteristic convulsive seizures; (4) by stigmata, such as sublin- 
gual ulceration, swollen upper eye-lids, oedema of the face, petechia?, 
and tender areas in the larynx; (5) pressing the tongue down and back 
with a spoon often elicits a characteristic attack of coughing. The 
stridor may be absent in nurslings and adults. The diagnosis may be 
difficult in intervals between paroxysms in the early or late stages. 
Intercurrent — especially febrile — diseases, like pneumonia or measles, 
may render pertussis atypical. 

Differentiation. — 1. Laryngeal diseases with spasm. 2. Acute glot- 
tis oedema. 3. Croup. In the latter there is fever, aphonia, metallic 
inspiration, lividity and constancy of the symptoms; i. e., no interval. 

4. False croup, (laryngismus stridulus) beginning with acute 
catarrhal laryngotracheitis, occurs at night in healthy children. 

5. An epidemic cough in babies (tusssi fernia) may occur epidemi- 
cally, but has no "whoop." 6. Spasmodic cough from disease in 
the bronchial glands. 7. "Ictus laryngeus" (vertigo or epilepsia 
laryngea), occurs in asthma, gout, tabes or laryngeal disease, and 
is recognized by burning in the larynx, vertigo and falling, as 
in apoplexy (ictus). 8. Spasmus glottitis occurs in nervous children 
at dentition, in cases of rhachitis and tetany; it is a sudden spas- 
modic closure of the glottis without prodromes, but with dyspnoea, 
cyanosis and convulsions. 9. Asthma periodicum (Millar's asthma) 
may develop in healthy children from the second to the sixth year, 
with hoarseness, moderate fever, dyspnoea on the second day, with 
convulsions, cyanosis, and repeated seizures. Recovery occurs, or 
death, within the first eight days of the disease. 10. Hysterical "after "- 
pertussis is characterized by the absence of catarrhal symptoms, fever, 
vomiting and the stigmata of pertussis; i. e., sublingual ulceration, 
darkly colored upper eye-lids, oedema of the face, petechia? and the 
tender point in the larynx, irritation of which induces an attack. Hys- 
terical imitation is associated with the stigmata of hysteria (q. v.), the in- 
fluence of suggestion and a longer course than that of pertussis proper. 



186 THE SPECIFIC INFECTIONS 

Prognosis. — Whooping-cough, with its complications, is a very fatal 
disease, and ranks third in the English vital statistics for children. 
Hirsch states that, in Prussia, 85,000 deaths occurred from pertussis 
from 1875 to 1880, and in England, from 1857 to 1867, 120,000 died 
from the disease. The mortality averages 3 per cent., but varies with 
the virulence of the epidemic, and may even reach 15 per cent. The 
longer the time of development of the convulsive stage, the better 
is the prognosis, and the clearer are the intervals between paroxysms. 
The outlook is more unfavorable in girls, in the poor, in nurslings 
and in children under five years, especially in colored children. The 
mortality of cases in the first year is about 27 per cent., in jthe second 
year 14 per cent.; from the second to the fifth year, 3 per cent.; from 
the fifth to fifteenth year, 1.8 per cent. (Hagenbach); Toplitz found 
41.7 per cent, of pertussis deaths in children under one year, and 48 
per cent, in children between one and two years of age. According 
to Trousseau, when more than forty attacks occur in one day, a grave 
prognosis is indicated and when over 60 attacks occur a fatal outcome 
is certain. The writer, however, has seen recovery in cases with over 
100 paroxysms daily. Coincident measles, pneumonia or bronchitis, 
especially if of early development, weak heart, purpura, continued 
emesis, glottis spasm, eclampsia, sinus thrombosis, skin emphysema, 
encephalitis, brain hemorrhage, asphyxia, and the sequels of scrofula 
and tuberculosis, render the prognosis very uncertain. 

Treatment. — 1. Prophylaxis. — Isolation is difficult, but is indicated, 
particularly in tuberculous children. It may be thought best to expose 
a child to a mild epidemic. The greatest danger exists during the 
catarrhal stage, although the coughing period is not devoid of it. 
The sputum, and the washing of clothes, etc., are cared for on anti- 
septic principles. It was thought that vaccination mitigated or aborted 
pertussis (Archer), but in eleven personal cases, which had never 
been vaccinated, vaccinia had no prophylactic effect. 

2. Medication. — There is no specific, as proved by the much- 
vaunted resolvents, emetics, demulcents, expectorants, antispasmodics, 
narcotics, tonics, and antiseptics. All drugs should be employed 
cautiously. The following are of value : Quinine, the foremost remedy, 
was first introduced by Binz, who gave 1\ times as many grains per 
diem as the child was years old; to children under two years, he 
gave ^ grain for each month. Children object to the taste of quinine less 
than do adults. 

Widerhofer's formula runs as follows: 

Extr. belladonnse gr. iss. 

Quininse sulph gr. viij . 

Sacchari albi gr. xxx. 

M. et divide in pulv. no. X. 

S. — One powder three times daily. 

Camphor, recommended by Jacobi, is a stimulant and may be indi- 
cated in asthenia and in increasing bronchitis, f grain at a dose. 



PERTUSSIS (WHOOPING COUGH) 187 

Antipyrin sometimes decreases the number and severity of the at- 
tacks; \ grain for each month or a decigram (1.5 grains) for each 
year is given, which may be gradually doubled. Bromine should be 
administered as bromide or bromoform (Stepp). It is not curative, 
but moderates the course of the disease. Bromoform should be kept 
bottled in the dark and should be administered fresh from the stock 
solution each time: one to five minims in simple syrup. 

The catarrh may be treated with expectorants and alkaline drinks. 
A steaming kettle will somewhat alleviate bronchitis, the child being 
kept in bed and a tent constructed over the bed. Intralaryngeal in- 
sufflations of resorcin (1 per cent, with starch) are recommended. 
Blenorrhcea should be treated with benzoic and tannic acids (aa gr. 
ij,t. i. d.). 

For the paroxysm there is no specific. Belladonna is given by Jacobi 
in the form of the extract, one-sixth grain to a child of six to eight 
months, until flushing is observed. Symptomatically it is also useful 
for the clammy, cool skin and for collapse symptoms. Though child- 
ren tolerate belladonna well, great care must be exercised with regard 
to the very young. The same caution is necessary with ipecac, chloral 
and Henoch's combination of belladonna and opium. 

Chloroform inhalations are dangerous. Codeine is less effective 
than morphia. Chloroform (Schilling) may be given with advantage 
in dry coughs, and twice as many drops may be administered as the 
child is years old. It should be given in one dram of warm water. It is 
said that the paroxysm may be averted by pulling the lower jaw down- 
ward and forward. 

Yeo recommends the following formulae : 

Morphinse hydrochloridi gr. J. 

Sodii bromidi 5ss. 

Aquae laurocerasi 5ij. 

Aquae chloroformi ad §jss. 

Misce, fiat mistura. 

S. — One to three teaspoonfuls for a dose, according to the age of the child. 

Chloral hydratis gr. xvj . 

Sodii bromidi ; gr. xxxij. 

Aquae chloroformi ad oij- 

Misce. fiat mistura. 

S. — One to four teaspoonfuls for a dose, according to age. 

Sodii benzoatis gr. lxxij. 

Sodii bicarbonatis gr. xlviij . 

Ammonii chloridi gr. xxiv. 

Aquae chloroformi 5j. 

Aquae anisi ad § iij • 

Misce, fiat mistura. 

S. — One to four teaspoonfuls, according to the age of the child, in a little hot 
milk, every four hours. 

Digitalis is used by Koplik and Knight for right-heart dilatation. 
O'Dwyer recommends intubation for the spasm of the glottis. This 



188 THE SPECIFIC IXFECTIOXS 

is open to the criticism that ulceration might occur from the long- 
continued pressure in the larynx. Bronchopneumonia (q. v.). 

3. Hygiene. — In warm climates pertussis is rare and runs a mild 
course. A suitable climate is likewise prophylactic against tubercu- 
losis. The attacks are often lessened, or the disease quickly ended, 
by removal to the country. Moderate exercise is indicated. Such 
irritants as beef tea or stimulants, dry bread, cookies (Vogel), and 
overfeeding or drinking, should be avoided, because they provoke 
coughing and vomiting in the convulsive stage. Food should be given 
at frequent intervals in concentrated form — gruels, milk with lime- 
water, zwieback in milk, eggs, malt, meat-juice, etc. Older patients 
can tolerate more solid foods. Rectal feeding and the use of the nasal 
catheter are. sometimes of advantage. 



EPIDEMIC PAROTITIS (MUMPS). 

Definition. — An acute specific infection, contagious, febrile, often 
epidemic, and characterized by a primary inflammation of the parotid 
glands. 

History. — Parotitis epidemica was known to Hippocrates, who de- 
scribed every essential point, but later it was confused with other 
swellings of the parotids and other diseases. Its distribution is world- 
wide. 

Etiology. — (a) Its precise cause is unknown, although various 
micrococci and diplococci have been described, (b) Most cases occur 
between six and fifteen years of age, although isolated cases are seen 
in adults and the aged, (c) The sexes are about equally involved. 
(d) More cases occur in the cold, moist, spring months than in the 
summer, (e) Contagion is more frequently direct from person to 
person than indirect by a third party or by fomites. (/) It prevails 
largely in epidemics, although sporadic cases are occasionally seen. 
(g) Immunity is, as a rule, conferred by one attack. It rarely prevails 
with scarlatina, varicella, measles or influenza. 

Symptoms. — After an incubation of two and a half to three weeks, 
the disease usually begins with fever, which is followed in a few days 
by parotid intumescence and pain. In some cases prodromes (slight 
fever, chilliness, and redness of the throat) may exist for thirty-six 
to forty-eight hours before actual fever and parotitis develop. In 
other instances the severity of the epidemic determines such severe 
initial symptoms as vomiting, convulsions, or facial spasm in children; 
or delirium, prostration, diarrhoea, or a severe typhoidal condition in 
adults. As a rule, the fever rises at the outset to 101° or even 104°, 
the pulse averages 100, and in two days the characteristic parotitis 
develops. Its signs are clearly inflammatory (swelling, pain, tempera- 
ture, and often interference in function). The parotitis is usually 
bilateral, for the inflammation of one gland is rapidly followed by 
parotitis in the other. Indeed, Bouchoud said: "Mumps have no 



EPIDEMIC PAROTITIS (MUMPS) 189 

singular"; but in some epidemics the parotitis is unilateral (Laveran). 
Its degree varies and sometimes there is partial swelling. Again it 
may be diffuse over the entire gland, or even beyond it. We know 
little of its pathology beyond what Virchow described — hyperemia of 
the parenchyma, interstitial swelling, catarrhal secretion in the ducts 
and inflammation of the contiguous lymph-glands. The swelling 
about the gland may reach the eyelids, forehead, mastoid region, or 
even the lower neck and clavicle, making the features unrecognizable. 
It seems that the swelling is due less to periparotitis than to pressure 
on the facial and other veins. It is soft and does not pit. In rare in- 
stances stasis and oedema may be noted in the pharynx or even in the 
larynx and with obvious danger. This may explain the occasional 
epistaxis. Compression by the swollen glands of the masticatory 
muscles makes chewing or opening the mouth difficult; chewing also 
excites pain because it excites salivary secretion which often cannot 
pass the turgid ducts. Compression of the Eustachian tube or external 
meatus may occasion tinnitus. In the early unilateral involvement, 
the face inclines to the affected side in order to relax the swollen 
tissues; in the later bilateral parotitis, the head is often bent for- 
ward for the same purpose. The salivary secretion may be normal, 
increased or decreased. Suppuration is rare and is probably due to 
mixed infection. Leukocytosis is usually absent. 

In severe cases the submaxillary and sublingual glands participate 
in the inflammation or swelling (even in 50 per cent, of some epidemics 
recorded) ; in atypical cases they may be the sole seat of the disease, 
and the parotids may be free from infection. The parotitic swelling 
reaches its acme in three or four days and an equal period is necessary 
for its subsidence. The course then is one week, or perhaps two. The 
fever throughout is remittent or intermittent, and falls by lysis in 
from four to seven days. One to two weeks are necessary for con- 
valescence. 

Complications and Sequels. — 1. The most important are orchitis 
and epididymitis, which were described by Hippocrates. On the 
sixth to the ninth day fever returns (102° to 105°), sometimes with 
chills and local redness. Swelling and pain in one testicle develop, 
and are often accompanied by general symptoms. Orchitis usually 
follows the parotitis, whence it was formerly considered metastatic. 
This view is untenable, because, in some epidemics, orchitis precedes 
or even occurs without parotitis. We must then explain mumps as 
a general infection, the blood carrying the virus first and most com- 
monly to the parotid glands and later (and even before or alone) to 
the testicle. A urethritis is sometimes observed, analogous to the 
catarrh of the parotid duct. It is sometimes held that this inflammation 
is the primary and atrial one. Testicular localization occurs almost 
wholly in the sexually mature and active testis and is therefore most 
rare in children or the aged. Orchitis or epididymitis is usually uni- 
lateral. It occurs in a variable percentage and depends on the char- 
acter of the epidemic. Comby observed it in 30 per cent, of cases of 



190 THE SPECIFIC INFECTIONS 

mumps among French soldiers. Acute hydrocele is due to the epi- 
didymitis. The fever occasionally resolves by lysis, and suppuration 
from mixed infection is very exceptional. Testicular atrophy occurs 
in 44 per cent. (Gramers) to 63 per cent, of the cases (Comby) and if 
bilateral may occasion sterility. In women, ovaritis and vulvovaginitis 
are infrequent. Mastitis is rather more frequent, and may be observed 
in men and boys. 

2. Other glandular organs are less frequently inflamed. Of these 
the lachrymal glands are most often affected, then the thyroid, with 
symptoms of acute Graves's disease, pancreas (1.5 per cent., Simonin), 
and the thymus. The spleen is seldom swollen. 

3. Other complications are very rare. These are severe delirium, 
meningitis, encephalitis, paralysis of the facial or other cranial nerves; 
polyneuritis, or the neuroses; labyrinthine or middle-ear disease, eye 
inflammations, optic neuritis; endocarditis; synovitis; albuminuria 
or nephritis; bronchitis or bronchopneumonia; necrosis, suppuration, 
or gangrene of the parotid or testis. 

Diagnosis. — -The diagnosis is usually easily made. Osteomyelitis of 
the jaw, periostitis, parulis, lymphadenitis, thrombo-phlebitis of the 
external jugular, and furuncle of the external ear, should be considered 
and excluded. Epidemic parotitis must not be confused with secon- 
dary parotitis, which results from trauma, or pus burrowing from the 
middle ear, or with mercurial, iodide or lead parotitis, and puru- 
lent metastasis in typhoid, pneumonia, and erysipelas, in which 
the pyogenic virus enters by the ducts or settles from the blood- 
current. In post-operative parotitis, after laparotomy, the saliva 
is decreased; anaesthesia first increases, then decreases the salivary 
flow; trauma to the gland, from holding up the jaw, may promote 
infection. 

Prognosis. — The prognosis is usually good, for but 7 deaths occurred 
in 58,331 cases. The course is lighter in children than in adults. 
Atrophy and sterility may result from orchitis. 

Treatment. — The patient should be isolated. The fever is controlled 
as in other fevers, and diet and hygiene are the same. Complications 
are treated symptomatically. The patient should be kept in bed for 
one and a half weeks. Pain often necessitates the use of opiates. 
The local parotid or testicular inflammation is self-limited, and re- 
sists all attempts at abortion or mitigation. Local heat is soothing and 
better tolerated than the ice-bag. 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER). 

Definition. — An acute, febrile, non-contagious disease, with multiple 
articular involvement and with a tendency to heart complications. 

Frequency. — McCrae's statistics, from Johns Hopkins Hospital, 
show that rheumatism constitutes 2 per cent, of admissions, as against 
3.5 to 7 per cent, in the London hospitals. 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER) 191 

Etiology. — Though strict proof is lacking that rheumatism is an 
acute infection, the evidence is strongly presumptive. This is shown 
by its occasional yet undoubted epidemiology; its clinical picture; 
its tendency to recur like pneumonia and erysipelas; the autopsy 
findings of exudation, hemorrhage, cloudy swelling, and acute splenic 
tumor; the frequency with which a suitable atrium may be observed, 
such as an angina, which furthers the entrance of microorganisms 
into the system; and its indubitable close affiliations with such dis- 
eases as endocarditis, pericarditis, and meningitis, whose mycotic origin 
is clearly established. Guttmann and Sahli found staphylococci in 
the joints, kidneys, and pericardium, and Leyden discovered a diplo- 
coccus. Sahli early questioned the unity of the disease and is now 
inclined to regard it as a modified septicopyemia. Birsch-Hirschfeld, 
Triboulet, Bouchard, Charrin, Singer, Alchame, and many others, 
have found bacteria not only in the joints but in the blood and vis- 
cera. If all observers found the same bacteria, conclusions would 
be more easily drawn, but the finding of streptococci, staphylococci, 
diplococci and bacilli creates confusion, and it must be stated that 
the rheumatism virus is unknown. 

Of late the Micrococcus rheumaticus, described by Triboulet (1898) 
and Wassermann (1899), has attracted especial attention. It is claimed 
that it differs from the ordinary streptococcus in changing the color 
of agar serum media and in growing on filtered media in which the 
ordinary streptococcus has already grown (Marmorek's test); in grow- 
ing best on very alkaline media and quickly secreting much acid. 
It is said to produce in the urine formic acid (which we find in rheu- 
matism) and produces hemolysis (like the rheumatic anaemia). Singer 
likens rheumatism to septicopyemia in that common symptoms 
occur in each — temperature, anaemia, articular metastases, endocar- 
ditis, leukocytosis, and peptonuria. He places particular stress upon 
the detection of pyogenic organisms in the rheumatic joints, in the 
initial angina, in endocarditis, in pneumonia, in erythema multiforme, 
in the various serous membranes involved, and in the urine. Chvo- 
stek and Egger explain the presence of these organisms by bacterial 
invasion of the tissues during the death agony, "an agonal invasion," 
since bacteria could not be obtained from aspiration of the joints 
during life. The rheumatic arthritis is sometimes explained by tox- 
aemia rather than by bacteriaemia, analogous to the toxic pericarditis 
of uraemia, or the swelling of the articulations after antitoxin injec- 
tions. Personally, the author can readily conceive of such a theory, 
inasmuch as he has repeatedly seen negative cultural results from 
aspirations of the synovitis of chronic nephritis, explained in some 
instances, at least, by retained toxins. Streptococcus or staphylococcus 
infections may produce a clinical picture resembling rheumatism or 
may indeed complicate it, but they are not found in the majority 
of cases of genuine rheumatism. 

Some writers question the "unity" of acute articular rheumatism, 
because the clinical picture is not always the same. Age modifies the 



192 THE SPECIFIC IXFECTIOXS 

disease, as is shown by the predominance of chorea, pericarditis, and 
endocarditis in childhood, with striking synovial subordination. The 
"genius epidemicus" changes the symptomatology, the disease dura- 
tion, the medicinal results, and the frequency of nervous, and endo- 
cardial complications, and of those of the serous membranes. The 
fact that the onset is accompanied by angina, enteritis, icterus, gas- 
tritis, bronchitis, and typhoid symptoms, is an argument against the 
theory of clinical independence of inflammatory rheumatism. However, 
no greater variations are noted than in other diseases, — e. g., in typhoid. 

Predisposing Factors. — (a) Cold; 75 per cent, of cases occur in 
the first half of the year (McCrae); (b) heredity (25 per cent.); (c) 
male sex (70 per cent.); (d) age, the greatest susceptibility exists 
between ten and thirty years (60 per cent., McCrae; 81 per cent., Dam- 
ash); M. Miller collected nineteen cases in nurslings; (e) trauma, 
overexertion, exhaustion, exposure, and occupation, occurring frequently 
in sailors, divers, bakers, and day laborers. 

General Clinical Picture and Course. — The onset is usually sudden, 
with moderate fever, redness of the skin, considerable prostration, 
drenching sweats and polyarthritis. The joints are involved in suc- 
cession, the inflammation lasting a few days in one joint and then 
passing to many others, with frequent heart localization and the fever 
ending in solution by lysis. There is marked anaemia and loss of 
weight. If endocarditis occurs, valvular disease is the usual sequence. 
The usual duration without therapy is three to four weeks, though 
abortive forms occur. Recovery is usual, but death may result from 
hyperpyrexia and from brain toxaemia. A tendency to recur and 
a family tendency in rheumatism' and valvular lesions are noted. The 
articular disease is directly influenced by the salicylates, but cardiac 
localizations are much less directly or not at all affected. In adults 
and adolescents there is febrile urine, constipation, conjunctival in- 
jection, coated, moist tongue, some irritability, restlessness, and fever 
which is renewed as fresh joints are involved. 

Symptoms in Detail. — 1. Prodromal Symptoms. — These are an- 
gina or tonsillitis (70 to 80 per cent., Garrod; 21 per cent., Gerhart; 
5 per cent., Groedel and Reiss; 1.7 per cent., Pribram), regarding 
which there are two conceptions; (a) that the angina is primary 
and rheumatic, and (b) that the rheumatism following angina is 
pseudorheumatism (polyarthritis anginosa), characterized by exan- 
thems, occurring chiefly in the arms and reacting poorly to salicylates. 
Mild gastric symptoms are considered by Damash as the most fre- 
quent prodrome. Other prodromes are laryngitis, otitis media, chorea, 
chlorosis, and erythema nodosum. Whether the prodromes are indef- 
inite or wholly absent, or whether they are angina, albuminuria and 
fever, as Widal has often seen them, or enteric, as often observed in 
Vienna, any diagnostic doubts are settled by the appearance of the 
polyarthritis. 

2. Polyarthritis. — (a) Localization. — The joints most frequently in- 
volved are those of the lower extremity, particularly the knee (53 to 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER) 193 

84 per cent.); and usually one side is affected after the other. The 
ankles, elbows and wrists are the seats of the next most frequent 
localizations. Though usually found in the large joints, it may in- 
volve the smaller articulations, such as the fingers. Early arthritis 
of the small bones of the carpus was thought by Trousseau to pro- 
mote endocarditis. Rheumatism may invade the spine, jaw, sterno- 
clavicular joints, the synchondroses of the ribs, the sacroiliac or pubic 
articulations, and the larynx. Occupation has a bearing on the dis- 
ease; for instance, rheumatism may occur in the arms of washer- 
women. If a joint of an upper extremity is first involved, the opposite 
arm is usually next inflamed: (b) In general the arthritis is ascending, 
fleeting and almost invariably polyarticular (Senator). The charac- 
teristic erratic character of the arthritis is mentioned by the oldest 
writers, as Van Swieten, who spoke of it as " migratory inflammation" 
or "fleeting gout." Though usually fleeting in its nature, the virus 
may settle in one joint for a considerable period, but persistency in 
one joint always suggests pseudorheumatism (symptomatic or secon- 
dary forms), (c) Signs and Symptoms. — Polyarthritis is a better term 
than polysynovitis because the inflammation pervades all structures 
of the joint, the periarticular bursse, cellular tissue, muscular inser- 
tions and tendons, and the external oedema is usually greater than 
the synovial effusion. Rattling over the joints is usually due to tendo- 
synovitis. The joints are swollen, red, tender and painful. Pain is 
the most prominent and frequent joint finding. Lasegue attributes 
the pain not to the joint but to inflammation in the associated muscles 
and tendons, affirming that if these be relaxed voluntarily by the 
patient or suitably supported by the physician, the joint can be moved 
freely in all directions. Lasegue's phenomenon is said to be absent 
in gonorrheal and surgical arthritis. The contiguous tendon reflexes 
are lessened or abolished, (d) Duration. — The joint inflammation 
remains in one joint from one to eight days, seldom longer, and its 
involution is shorter than its evolution. (e) Sequels. — The joints 
become quite normal; ankylosis is so infrequent that its occurrence 
usually reflects doubt upon a previous diagnosis of rheumatism. 
Suppuration is extremely exceptional, but may result from mixed infec- 
tion and more frequently in children than in adults. Spontaneous 
dislocations are rarities. 

3. Temperature. — The temperature is directly related to the inten- 
sity of infection, the number of articulations involved, and to the de- 
velopment and progression of visceral complications. As Wunderlich 
noted in his celebrated communication on fever, the temperature is 
usually highest when the patient is first examined. The fever rises 
with each new localization, be it arthritic, endocarditic, or pericarditic . 
Friedlander spoke of a short (monoleptic) and a long cycle (poly- 
leptic), yet the fever curve is in no wise cyclic, beyond undulation with 
each new manifestation, and is rarely higher than 102° or 104°. The 
temperature is usually seen to drop when the sweats occur. Pro- 
dromal fever was early noted by Todd, Graves and Fuller. The 

13 



194 THE SPECIFIC INFECTIONS 

fever averages ten days, defervescence occurring spontaneously or 
with the salicylate therapy. The fever is longer when treatment is 
commenced late. Kahler held that fever could occur independently 
of joint inflammation (febris rheumatica). Pleuritis, renewed arthritis, 
angina, erythemata, embolic and other complications, prolong the 
pyrexia. Simple fixation of the joints reduces the fever, tachycardia 
and tachypncea (Pribram). Chills suggest septicopyemia rather 
than rheumatism. Hyperpyrexia is exceptional. The fever may, 
however, even reach 111° with severe nervous symptoms (" cerebral 
rheumatism"), coma, convulsions, rapid pulse, transitory paralysis, 
and stertorous breathing. 50 to 60 per cent, of cases of hyperpyrexia 
occur in the first attack of polyarthritis with lesser frequency in later 
seizures. It is less frequent since the introduction of the salicylates. 

The pulse is accelerated and is usually said to exceed 100, although 
McCrae found that its rate was not over 100 in 59 per cent, of his cases. 
Dicrotism and arrhythmia may sometimes be noted before involve- 
ment of the joints. The respiration follows the fever; Pribram noted 
one case with 80 to 100 per minute. 

4. Heart Complications. — These are almost an integral part of 
rheumatism and constitute visceral rheumatism as distinguished from 
articular rheumatism. Heredity seems to be a factor in certain cases. 
Heart lesions occur as frequently in light as in severe forms. They 
vary somewhat with the epidemic, are most frequent at the time of 
puberty when they are most dangerous, and increase in frequency 
with repeated attacks of rheumatism. Lasegue says: " Acute rheu- 
matism licks the joints, the pleura, and even the meninges, but it 
bites the heart." 

(A). Endocarditis. — This, the most vital complication, was first 
described by Pitcairn (1788), and Pidoux, Besnier and Homolle fol- 
lowed Bouillaud in developing the subject. Bouillaud (1832) formu- 
lated the statement that " in every severe, generalized case of acute, 
febrile rheumatism, endocarditis was the rule." At the present time 
many French writers hold the same view. Besnier and Widal main- 
tain that in severe cases the " heart is diseased to some degree." The 
frequency of endocarditis is about 20 per cent. (Other figures are 
50 per cent. Damash, Fuller, Latham; 40 per cent. Pribram; 20 
to 28 per cent. Bamberger, Jaccoud, Oettinger.) Mackenzie finds endo- 
carditis in 58 per cent, of first attacks, 63 per cent, of second attacks, 
and 71 per cent, of third attacks. In McCrae's series we might divide 
the cases into thirds; in one third, the heart is normal; in another 
third, it is doubtful; and in the last third, it is diseased. Hospital 
statistics are somewhat misleading, because they represent the severest 
cases. Clinically, endocarditis often escapes recognition, or is latent; 
— i. e., it is found more frequent at the autopsy table than at the bed- 
side. It is usually verrucose, and rarely ulcerative, even in the fatal 
cases. Accidental or "functional" murmurs must not be called endo- 
carditis. To be certain that an endocarditis exists, two points are 
absolutely necessary: (1) Continued observation of the patient after 



ACUTE ARTICULAR RHEUMATISM {RHEUMATIC FEVER) 195 

convalescence; (.2) attention to signs of valvular disease (q.v.), other 
than the mere murmur, such as dilatation, hypertrophy, and secondary 
pulmonic accentuation. The distinguished Trousseau called atten- 
tion to the possibility of the functional murmur. Potain, almost alone 
among the present French writers, properly estimates its importance. 
The diagnosis of acute endocarditis must long be uncertain. Accord- 
ing to Leube, functional murmurs are rare in rheumatism, though 
Senator considers them frequent; yet therapeutically we must keep 
on the side of extreme caution by keeping the doubtful case sufficiently 
long in bed. We may interpret the disappearance of a murmur in 
two ways, — first, as the disappearance of a functional murmur when 
the fever falls, the toxaemia disappears, the heart slows, and dilatation 
subsides, or the anaemia mends; or, second, as the healing of a slight 
endocarditis, though this is always the less probable issue. 

Valves Affected. — McCrae finds the mitral valve involved in 95 per 
cent, of the cases, the aortic in 23 per cent., and both valves in 18 per 
cent. (Aortic lesions are usually estimated at 12 per cent.) The fever 
may be continuous with that of the arthritis but is often higher. Less 
often the fever is remittent with severe rigors and may require differen- 
tiation from malaria, pyaemia, or gonorrhceal endocarditis. A low 
remittent fever may suggest pulmonary or serous membrane tubercu- 
losis. The endocarditis exceptionally antedates the polyarthritis (Jac- 
coud, Trousseau). 

Masked or atypical rheumatism was known to Immermann, who 
spoke of rheumatism masquerading under the guise of an endocarditis 
or trifacial neuralgia and yielding to salicylate treatment. Kahler's 
opinion of rheumatic fever without arthritis has been mentioned. 
The rheumatic virus is claimed to sometimes produce pericarditis or 
endocarditis without articular inflammation — "polyarthritis rheumatica 
sine arthritide." We may call this the " rheumatic equivalent/' bor- 
rowing from the nomenclature of epilepsy. 

In old heart lesions with renewed rheumatism, lingering fever sug- 
gests the possibility of an exacerbation of the old endocarditis which 
may have been aroused by the last rheumatic attack. Various em- 
bolisms may occur. The bacteriological findings are most varied, 
and not knowing the actual cause of rheumatism, we cannot say ex- 
actly what is rheumatic and what is mixed infection. Many cultures 
are negative. 

(B). Pericarditis. — Osier states that rheumatism explains more 
cases of pericarditis than all other causes combined. It is the most fre- 
quent lesion in children. Its frequency is variously given as 20 per cent. 
(Hache, Wunderlich, Leudet, Sibson); 54 to 70 per cent. (Williams, 
Omerod, Taylor) ; 13 per cent. (Chambers) ; 10 per cent. (Oettinger) ; 
6 per cent. (McCrae), 5 per cent. (Pribram). Pericarditis is very fre- 
quently latent. In children, especially, a subacute or latent course 
ending in synechia is most common. Baginsky found that adhesive 
pericarditis was the most common autopsy finding in rheumatic chil- 
dren. 



196 THE SPECIFIC INFECTIONS 

(C). Myocarditis. — Disturbance of the heart in the acute stage is 
almost certainly myocardial. It may be toxic or mycotic. Acute inter- 
stitial myocarditis (in 28 per cent. Poynton), changes in the heart 
ganglia, coronary embolism or thrombosis, direct myocardial invasion 
bv contiguity from endocarditis in the later stages, and sometimes 
the use of salicylates or antipyrin, are possible causes. Recovery is 
usual, but chronic fibrous myocarditis is a not uncommon sequel. 
Acute myocarditis may produce a systolic murmur, and confusion 
with early endocarditis is possible. Myocarditis may cause sudden 
heart pain with weakness, in which case the subject may die. This 
is the "heart rheumatism'' of the laity. Transient palpitation, fugi- 
tive cardiac oppression, or tachycardia, due to pain or excitement, may 
occur. Bradycardia with vertigo and syncope is probably myocardial. 

As a practical point, it must be remembered that the right heart 
may be dilated as in other fevers and as in various abdominal affections; 
this dilatation disappears with convalescence. When accompanied by 
a murmur it may lead to an incautious and wholly unjustified diag- 
nosis of endocarditis. The bloodvessels are rarely inflamed, but 
coronary or peripheral endarteritis occasionally develops. French 
writers maintain that acute arteritis is common; severe pain, well 
localized over the artery, is followed by parsesthesia and pain over 
its smaller branches and in the extremities; pathologically only part 
of the vessel-wall is affected and healing usually follows, but gangrene 
may develop after complete arterial occlusion. Endophlebitis is 
somewhat more common. 

5. Skin. — Sweating is most profuse, constant and characteristic; in 
odor it is sour or mouse-like (Schoenlein) ; in reaction it is first acid 
and later neutral or alkaline. This may result from decomposition 
or from large doses of alkalies. The skin is frequently macerated 
and sudamina are common, usually sudamina alba (in 4 per cent., 
sudamina rubra). Rheumatic nodes (first described by Hilliers, Mey- 
nert, Hirschsprung, Barlow and Warner) are subcutaneous nodes, as 
large as buckshot, and occur mostly on the fingers, hands and wrists, 
but also on the elbows and spine. They may appear during or after 
an attack, or independently of acute seizures. They occur especially 
in children, but are also observed in adults, and particularly in women. 
They are abundant, sometimes numbering even sixty, are frequently 
symmetrical, hard, and are usually tender. Sometimes osseous or arterial 
endothelial proliferation is observed. Nodes occur most often in 
chronic cases or in cases with severe endocarditis or pericarditis. If 
very numerous or large they indicate an unfavorable prognosis. In 
contradistinction to these more fixed nodosities, Fereol has described 
more fugitive and less indurated nodes, which are rather analogous 
to the fugitive polyarthritis {nodosities cutanees ephe 'meres). (Edema 
of the skin (Comby. Ferret, Guyon) may be septic, rheumatic, or 
angioneurotic. Erythema polymorphum is generally regarded as an 
independent affection but in rheumatism it does occur in the nodose 
or vesiculated forms. Some cases are possibly septic or anginose 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER) 197 

eruptions. The salicylates relieve some cases and fail to benefit others. 
Morbilliform or scarlatiniform rashes are infrequent, and may be attri- 
buted in part to errors in diagnosis, or to drug eruptions. Purpuric 
eruptions are not uncommon. The intestinal hemorrhage, colic, and 
vomiting, with articular intumescence, described by Henoch, are en- 
tirely distinct from genuine rheumatism and will be considered under 
Purpura (q. v.). 

6. Muscles and Bones. — Myositisis infrequent, though myalgia is com- 
mon. Muscular atrophy may follow inflammatory extension from the 
joints to the muscles. "Muscle scars" are not frequent, and are much 
more often due to trauma, to other infections, to septicopyemia, poly- 
myositis and dermatomyositis than to rheumatism, which rarely seems 
causal, although undoubtedly sometimes coincident. Cases of torti- 
collis in children have recently been considered instances of cervical 
rheumatism. Periostitis may occur, and is thought by some authori- 
ties to be latent syphilis aroused by rheumatism. Some cases of al- 
buminous periostitis are clearly rheumatic. Isolated instances of 
osteomyelitis (deforming rheumatism) are possibly rheumatic. 

7. Respiratory Tract. — Laryngitis may be prodromal. It may be 
a possible atrium for a systemic invasion, or may occur later as 
diffuse catarrh or as local nodes. The rare acute oedema of the 
larynx is most dangerous. Pleurisy may result from the rheumatic 
virus even when it shows wholly negative bacteriological examinations 
or it may result from secondary infections. Its frequency is 2 to 3 
per cent, (to 4 to 6 or 10 per cent.). See described two types (a) a 
violent and (b) a mild (latent) form, both of which usually run a favor- 
able, rapid course, perhaps with considerable fever. A primary pre- 
arthritic pleurisy (Fiedler, Lasegue) is very rarely observed. Pleurisy 
and pneumonia are usually associated with heart disease. Pleurisy 
is found in 54 per cent, of cases of endopericarditis (Pribram). While 
the writer has occasionally seen cases of serous pleurisy in association 
wirh rheumatism, he believes that the so-called rheumatic pleurisy is 
almost always tuberculous (see Etiology of Pleurisy). Pneu- 
monia occurs in but one-tenth of 1 per cent, of cases of rheumatism 
not involving the heart, and in 66 per cent, of cases with endoperi- 
carditis. Howard (quoted by Osier) found lung and pleural com- 
plications in only 10 per cent, of cases with rheumatic endocarditis, 
in 58 per cent, of those with pericarditis, and in 71 per cent, of those 
with endopericarditis. These figures seem remarkably high, and with- 
out questioning their accuracy, it is certain that many cases are called 
pneumonia which are pulmonary infarction, stasis, or compression 
from pleural or pericardial exudates. French writers describe two forms 
of pulmonary complications: (1) The forme pneumonique (Besnier, 
Herzog, Hirsch), which is fugitive or migrating (pneumonia migrans). 
It may even appear before arthritis. It is said to be less typical in 
onset and solution; in the sputum; in absence of cyanosis and dys- 
pnoea; in its asthenic prolonged course; and in its lobular develop- 
ment and incomplete hepatization; (2) the forme oedemateuse (Houdet, 



198 THE SPECIFIC INFECTIONS 

Ball, Bernheim), in which oedema may be widespread, may resemble 
the acute pulmonary oedema of Bright's disease, or may be localized 
in one lobe or in the bases. 

8. Digestive Tract. — Angina or tonsillitis often occurs as a prodrome 
(v.s.) or as a later development. The tongue is coated and moist 
except in the severest cases where it is dry. The salivary secretion 
,is sometimes acid, and increased sulphocyanides have been noted. 
Gastric symptoms are rare, except from such rare complications as 
meningitis and uraemia, though Damash considers that gastric disturb- 
ance is the most frequent prodrome. Constipation is the rule. Diar- 
rhoea occurs as prodromal enteritis or as a rare complication, and is 
rarely bloody. Peritonitis, icterus and liver enlargement are most 
exceptional. 

9. Genito-Urinary Tract. — Cystitis resulting from the use of canthar- 
ides blisters has been noted by Lebert, Senator, and by Homolle. 
Pribram considers it suggestive of gonorrhoea. Fibrinuria is very in- 
frequent. Acute nephritis is seldom seen ( T 3 o to 1 per cent.); it occurs 
early, and chiefly in endopericarditis, and is usually benign but may 
become chronic. Renal infarction usually occurs late in the course 
of cardiac cases, and kidney suppuration indicates the pyogenic 
pseudorheumatism. But few of the author's cases in private practice 
show nephritis, though it is present in 75 per cent, of hospital patients. 
In these it is probably latent until awakened by the fresh toxaemia; 
it is probably due to their social status, vagabondism, exposure and 
alcoholism. Albuminuria is mostly transitory. It occurs late in the 
course or after several attacks, and mostly in individuals over thirty 
years of age. The percentage ranges up to 34 (McCrae). Albumo- 
suria is frequent, especially during resorption, whence it has a 
slight diagnostic value. Cylindruria may occur without albuminuria; 
hsematoporphyrin has been found, also urobilin, formic acid, sugar, 
the characteristics of fever urine, reduction of the chlorides and bac- 
teria (sepsis). The sexual organs are involved chiefly in gonorrhoeal 
pseudorheumatism. Amenorrhcea is usual. Uterine atrophy, hemor- 
rhagic endometritis and genital hemorrhage are infrequent. Rheu- 
matic arthritis as well as gonorrhoeal "rheumatism" may occur in 
pregnancy. In the puerperium, gonorrhoeal, septic or endocarditic 
joint inflammation may occur (see Diagnosis). 

10. Blood. — The blood shows increased fibrin and, in low dilu- 
tions, is said to sometimes respond to the Widal reaction. The red 
disks are reduced 25 to 30 per cent, and chlorotic characteristics are 
noted. The fever, the anaemia and the intensity of articular involve- 
ment run more or less parallel (Hayem and Garrod). The white 
cells, in moderate cases, range between 10,000 and 15,000, and higher 
figures (20,000) are only reached in extensive endocarditis, pericar- 
ditis, pleurisy, pneumonia, or in septicaemic pseudorheumatism or 
suppurative arthritis. The increase is in the polymorphonuclear neu- 
trophiles while other cells are normal or decreased. The eosinophiles 
are practically absent, but increase with betterment of the articular 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER) 199 

findings. If they are increased in a florid case, the prognosis is good, 
since the course will probably be mild. Bacteriological findings are 
(1) negative, or (2) positive from mixed infection. 

11. Nervous System. — The relation of chorea to rheumatism is 
an unsettled question. Chorea, rheumatism and endocarditis are 
associated (in 50 per cent, of cases, Pribram), or coordinated, and 
possibly a common, though unknown, infection is the essential cor- 
relating cause. A constant anatomical cause of chorea, as arterial 
change, encephalitis, or embolism, is not known. Cases with rheu- 
matic or endocarditic association usually run a slow and often a 
relapsing course; cases which react to the salicylates are probably 
rheumatic. Cerebral rheumatism is very infrequent; it may develop 
acutely at the acme of the disease, with psychical alteration, often with 
hyperpyrexia, sometimes with warnings, or again precipitately. Delir- 
ium, unrest, convulsions, and coma, frequently result in death. High 
fever may be solely a cerebral symptom, but cerebral symptoms may 
occur without high temperature. The course is foudroyant or lasts 
several days, and even a week. Drug poisoning, alcoholism, inanition, 
previous exhaustion, hysteria, and the temperament cerebrate are pos- 
sible factors. The author has seen one case of recovery after mania, 
convulsions, meningeal symptoms, and coma. Chronic psychoses, hal- 
lucinations, sopor, mania, coma, convulsions, or melancholia, may 
occur in convalescence. They are usually due to inanition and the 
patient generally recovers. Brain embolism (from endocarditis), 
hemorrhage or rheumatic meningitis, are infrequent, and are not 
classed with the above varieties. Spinal rheumatism may be confused 
with myelitis, septic or gonorrhceal meningitis, multiple neuritis, local 
myopathies adjacent to the joints involved, or cerebral embolism. 
Exaggerated tendon reflexes, decubitus, and vesical paralysis, occur in 
some rheumatisms. In Kraus' clinic the author saw one fatal case 
characterized pathologically by meningomyelitis. Multiple neuritis 
is often rheumatic; it may precede the polyarthritis, but usually 
occurs in the first or second week of rheumatism and presents the 
usual characteristics, such as pain and tenderness over the muscles 
and nerve trunks, paralysis, muscle atrophy, skin dystrophy, reaction 
of degeneration, anaesthesia and lost reflexes. The prognosis is good 
and the neuritis reacts well to electrotherapy. Mononeuritis occurs 
in the oculomotor, sciatic, trigeminal, and other nerves, and usually 
regresses entirely. 

The Eye. — Rheumatism may result in benign episcleritis, iritis, 
iridocyclitis, and possibly conjunctivitis. Optic neuritis, with or 
without atrophy, and retinal embolism or thrombosis occur exception- 
ally; their prognosis is doubtful. 

(Acute thyroiditis is most uncommon. Lymphadenitis is not un- 
common, but is rarely marked or extreme. It occurs, with arthritis, 
erythemata, endocarditis or pericarditis.) 

Prognosis. — The prognosis as to life is usually excellent and is 
generally proportionate to the severity and duration of the infection 



200 THE SPECIFIC INFECTIONS 

and to the number of joints involved. The percentage of deaths is 

1.5 per cent. (Rubin); 3 per cent. (Lebert, Eichhorst, Raymond) 

3.6 per cent. (Senator), or 3.7 per cent. (Roth), but these are hospital 
figures and therefore higher than in general practice. The death-rate 
varies with the geography of the disease; e. g., in Ireland 2 in 1,000 die, 
in New South Wales, 3; in New York, 3; in Paris, 4+; and in Scotland 
the rate, including deaths from heart lesions, is nearly 5. In statistics 
other arthritides are not carefully excluded. There are waves of 
increased mortality every three or four years. In late years the death- 
rate has somewhat decreased. The causes of death are (1) hyper- 
pyrexia, the most important; (2) cerebral rheumatism, chorea; (3) 
peri-, endo- and myocarditis; (4) pneumonia, lung infarcts. Recur- 
rences occur in 19 per cent, of cases (Church) or in a larger percent- 
age in general practice. They are more dangerous in pregnancy or 
with complications such as influenza, etc. The prognosis is less 
favorable in children than in adults. The salicylate therapy influences 
the disease and also its relapses; but the heart complications are 
only slightly or indirectly relieved. There is some danger of rheuma- 
tism becoming chronic. At the onset it is impossible to declare the 
case light or severe. According to Trousseau, the involvement of 
the small joints of the hands and feet justify the prediction of a severe 
course. 

Diagnosis. — 1. Rheumatism in Childhood. — In the very young the 
disease is most rare (3 cases in 85,000 nurslings) but becomes more 
common after the fifth year. The course is more rapid and the urine is 
normal or less febrile. Generally speaking, the joints are less suscep- 
tible and the arthritis less intense, while the skin, nervous system, and 
heart, are more often involved. Heredity is most potent in the young, 
and the sexes are equally involved. The various phases of rheumatism 
occur separately, — first arthritis, then endocarditis, later chorea, sub- 
cutaneous nodules, pericarditis, and so on. The child rarely lies quietly, 
but tosses about; the tendons and fasciae are more often involved than 
the joints, and in this the rheumatism may simulate talipes. The 
pain is less and the arthritis may entirely escape recognition. The 
lower temperature is particularly remarkable at this epoch of life, 
when high fever is often excited by trivial lesions. There is much 
less sweating. The aneemia in childhood is especially marked, 
and is as rapid in development as that of diphtheria or that of 
malaria in adults. In children the differential possibilities are 
acute osteomyelitis, acute pyaemia, monarticular arthritis, especially 
of the knee and hip in nurslings, gonorrhoeal arthritis, Barlow's 
disease, syphilis, hemophilic joints, and infantile palsy; if the 
rheumatism occurs in the spine, meningitis or torticollis are of dif- 
ferential importance. Endocarditis is usually not so clearly nor so 
immediately connected with the polyarthritis as in adults, but it devel- 
ops more slowly, insidiously, later, and twice as frequently as in adults 
(80 per cent. Vernay). Thomas Watson knew but three instances of 
acute rheumatism, before puberty, which escaped severe heart disease. 



ACUTE ARTICULAR RHEUMATISM {RHEUMATIC FEVER) 201 

This is due to the greater functional demands on the child's heart and 
to the aorta being narrow at the isthmus. Endocarditis occurs rela- 
tively early in what Cheadle terms the "rheumatic progression/' but 
pericarditis occurs later after the valvular lesion has inaugurated hyper- 
trophy and dilatation. Pericarditis is almost always found (Sturges) 
in necropsies on children with valvular disease. Rheumatic heart dis- 
ease in general at this epoch, leads to greater hypertrophy because of 
greater nutrition, to more marked dilatation because of greater tissue 
elasticity, and to more frequent recurrence. The prognosis is there- 
fore much more unfavorable than in adults. In the diagnosis, func- 
tional murmurs are not frequent in children, although they do 
occur. The pulse is often irregular; the precordium more readily 
bulges; left-sided pleurisy is more frequent than in adults, and 
delirium and rheumatic nodes are more common. Oppression 
over the heart is infrequent, as are pain, cyanosis, dropsy, hepatic con- 
gestion, pulmonary infarction, dyspnoea and fever. Rheumatic children 
are more nervous and more inclined to night terrors, and to anaemia. 
More marginate, papular and urticarious erythemata and more purpura 
develop in children. Large subcutaneous nodes (rheumatismus nodo- 
sus) are serious prognostically and always suggest danger from severe 
intercurrent valvulitis. Chorea is prone to develop with arthritis, 
heart disease, nodes, or with the erythemata. 

2. Anomalous Rheumatism. — By anomalous rheumatism we mean 
mixed infections, — e. g., rheumatism with gonorrhoea. Typical rheu- 
matism is easily recognized, while diagnosis in the masked or abortive 
variety is always problematical. 

3. Rheumatoides. — Rheumatoides (Gerhardt) or pseudorheumatism 
(Bouchard) are symptomatic arthritides resembling rheumatism in 
that fever, arthritis, or endocarditis, may occasionally develop in their 
course. The nomenclature of Quincke, who speaks of polyarthritis 
gonorrhoica, scarlatinosa, etc., is the least objectionable, (a) Poly- 
arthritis gonorrhoica resembles rheumatism most closely and most fre- 
quently. Koenig holds that the most common of all joint diseases is 
the gonorrhceal (v. Gonorrhceal Infection), (b) Polyarthritis scar- 
latinosa often most closely resembles rheumatism, occurs early or more 
frequently in the third to the fourth weeks of scarlatina, and varies 
with the epidemic (0 to 6.3 per cent.). In 66 per cent, of patients it 
occurs in the hands, and lasts four days, frequently with endocarditis 
or pericarditis (32 per cent. Hodges), and sometimes with recurrence 
and serous or purulent exudation. With it have been observed nodes, 
erythema and chorea, (c) Polyarthritis may also complicate many 
other diseases including most of the infections; measles, smallpox, 
varicella, erysipelas, dengue, malaria, typhoid, typhus, Malta fever, an- 
gina, appendicitis, diphtheria, syphilis, dysentery, pneumonia, influenza, 
recurrent fever, epidemic meningitis, neuritis, mumps, bronchiectasis, 
glanders, osteomyelitis, pyaemia, puerperal fever, septicemia, tubercu- 
losis, purpura, peliosis, scurvy, haemophilia, anaemia , ervthema-nodosum, 
Addison's disease, psoriasis and some neuroses and intoxications. 



202 THE SPECIFIC INFECTIONS 

4. Severe Types. — In grave types of genuine rheumatism the vis- 
ceral findings may be confusing but are least so when secondary, both 
in development and degree, to the arthritis. Jaccoud speaks of the 
primary visceral type, wherein the findings (e. g., pulmonary or car- 
diac) antedate the arthritis, but here the diagnosis remains uncertain, 
until involvement of the joints develops. 

5. Gout (q.v.). 

6. Arthritis Deformans (q.v.). 

7. Tuberculous Polyarthritis (q.v.). 

The number of joints involved is always highly suggestive, but not 
finally diagnostic. True rheumatism and gonorrhceal rheumatism are 
often polyarticular. Diagnosis of gonorrhceal rheumatism in women 
is often difficult for notable reasons. In women, puerperal infections, 
and an acute monarticular osteoarthritis, beginning acutely from 
exhaustion in pregnancy or lactation, may cause difficulty. In grow- 
ing children, acute osteomyelitis may cause articular swelling, which, 
however, is monarticular. 

Treatment. — I. Diet. — The diet should be limited to fluids, arrow- 
root, milk, gruels, etc. Biot's results, with a strict milk diet, were ex- 
tremely good. 

II. Clothing. — The patient should wear a flannel gown and lie 
between blankets, which are more comfortable than sheets on account 
of the sweating. Care must be taken lest the drenching sweats macer- 
ate the skin. This can be avoided by dusting talcum powder in the 
axilla? , between the toes, etc., and by sponging the body with warm 
water and alcohol. 

III. Local Treatment — Fixation lessens pain, fever, pulse and res- 
piration-rate. Cold applications, boric fomentations, and salicylic 
salve are useful [Acidi salicylici 5j> Adipis lanse hydrosi gj]. Davies' 
cantharides blister and the actual cautery are indicated for tardy 
involution. 

IV. Rest. — The patient should be in the position in which the 
greatest comfort can be obtained and in which there is the least dan- 
ger of ankylosis. Splints afford relief to the muscles and joints, but 
muscular atrophy may result from the use of plaster-of-Paris casts. 
The absolute dorsal decubitus, long into convalescence, or at least for 
two weeks, must be enforced because of the weak condition of the heart. 

V. Salicylate Treatment (Kolbe, 1874, Buss, 1875, and Strieker, 
1876). — 1. Effect on the Arthritis. — The pain and swelling are 
usually relieved after three to five full doses have been taken, or after 
twenty-four hours from the taking of the first dose. Salicylates are 
the best analgesic in rheumatism. Hypodermics of morphine are 
rarely necessary, except, perhaps, in the first twelve hours. 

2. Effect on the Temperature. — The fever falls coincidently 
with relief of the articular symptoms, and reaches normal in two 
days. In the great majority of cases the acute stage is over within 
three days. In hyperpyrexia less influence is noted, especially if the 
salicylates are administered late. 



ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER) 203 

3. Effect ox the Endocarditis. — Though some consider the sal- 
icylates specific, the general evidence is that endocarditis occurs as fre- 
quently with their use as without it, — i. e., salicylates are analgesic 
and antipyretic but not strictly antirheumatic. Many, however, claim 
that the salicylates are in every sense antirheumatic. The personal 
belief of the writer is that the salicylates are practically specific and 
that heart complications are lessened by shortening of the acute stage. 

4. Relapses. — Relapses are claimed to be more frequent with the 
administration of the salicylates than with the alkaline treatment, and 
especially so when treatment is discontinued early. This claim seems 
unfounded. Relapses are apparently less frequent with the continued 
use of salicylates for two weeks after the initial symptoms are relieved. 

Physiological Action of the Salicyl-preparations. — They 
are absorbed from local applications. The smallest doses produce 
such symptoms as cinchonism, fulness of the head or roaring in the 
head and ears. After larger doses dulness, headache, giddiness, a 
flushed dusky and moist skin, disturbed sight and hearing, and tremor, 
develop. Toxic doses produce the above symptoms, plus eye-muscle 
paralysis, pupil dilatation, deafness, increased reflexes, restlessness, 
delirium, dyspncea, disturbed circulation, skin eruptions, sweating, 
and also green urine. Postmortem breaking down of the blood, 
visceral congestion, and serous ecchymoses are seen. 

Administration. — Sodium salicylate is the best preparation. Its 
action is most prompt and certain; it is soluble and least irritating. 
Where it fails, other preparations are usually unsuccessful. All salicyl- 
preparations are absorbed as sodium salicylate produced by the alka- 
line intestinal juices. Grains xv of the natural acid, which is better 
than the synthetic, or grains xx of the sodium salt, are given every two 
or three hours until cinchonism appears; i. e., until slight dulness, 
dyspncea and deafness develop. This action is maintained for twelve 
hours, when the interval between doses is lengthened to four or six 
hours. The effects are better in proportion as the disease is more 
acute, the symptoms more pronounced, the inflammation greater, the 
number of involved joints larger, and the fever higher. It is well 
tolerated by children and usually can be given by mouth in fluid, if 
the taste be disguised by wintergreen oil, syrup of ginger, and syrup 
of orange. Even then, however, it is frequently nauseating. 

Sodii salicylates 5vj. 

Sodii bicarb oiv. 

Syrupi zingiberis . . . oj- 

Syrupi aurantii oj- 

Aquae q.s. ad oiv. 

M. et S. — One teaspoonful every three hours. 

Theoretically it should not be given in capsules for in this form it 
may irritate the stomach, but it may be given in powders which are 
taken in starch wafers. Because the action of sodium salicylate is 
analogous to that of quinine, bromide of potassium may be given to 



204 THE SPECIFIC INFECTIONS 

lessen the ringing in the ears. In case the stomach is intolerant, sal- 
icylates may be administered in pepsin, or given by rectum in pepton- 
ized milk. When given as an inunction, it is soon found in the urine, 
but absorption by the skin is uncertain. Aspirin is less irritating to 
the stomach than salicylate of soda. It is given in doses of five to 
ten grains at the same intervals. Salol (Phenylis salicylas) is given 
in the same dose at the same interval, but the kidneys must be care- 
fully watched. 

The alkaline treatment is said to decrease the heart complications 
and shorten the disease. Though these claims are not established, 
the alkaline treatment may be used in conjunction with the salicy- 
lates, using vichy salts with enough citrate of potassium or bicarbonate 
of soda to make and keep the urine alkaline. Long ago Fuller advised 
the following: — 

3 .. , 

Sodii bicarbonatis 5ss. 

Potassii acetatis 5ss. 

Liquoris ammonii acetatis 5iij. 

Aquae • • a d Bij. 

M. f. haust. 
S. — To be taken in effervescence with — 

Acidi citrici 3ss. 

Aquae §ij. 

Baginsky thinks that the administration of gr. xv to xl of potassium 
iodide daily produces better results in children than do the salicylates. 
Unusual Results. — Unusual results of salicylate treatment: 

1. Nervous. — Salicylate delirium has been observed in aneemic girls, 
neurotics, and in alcoholics. It may be violent and protracted. Con- 
vulsions are quite infrequent; they are centric. 

2. Cardiac. — Small doses stimulate the heart, and cardiac depres- 
sion is observed only when the largest dosage is given, when the 
preparations are impure, or when the heart is already diseased. If the 
heart becomes weak or irregular, acute myocarditis is probably devel- 
oping and salicylate treatment must be suspended, the dose must be 
decreased, or the heart muscle must be stimulated by coffee, strychnine 
or alcohol. Slight irregularity without weakness is not a contraindica- 
tion. Cardiac depression may be noted in nervous subjects. Thorne 
has observed collapse from aspirin. 

3. Respiratory. — With antecedent or concomitant bronchitis, the 
lungs should be explored for possible congestion which may result 
from the remedy. Cardiac depression, sudden respiratory failure and 
violent expiratory dyspnoea are observed in a few cases. Tuberculous 
patients should be carefully watched. 

4. Renal. — Caution is necessary in old nephritics, because the sal- 
icylates are excreted by the kidneys as salicylic, oxalic, or salicyluric 
acids and as salicin; however infective albuminuria, directly due to 
the rheumatic virus, indicates, rather than contraindicates, the use of 
the salicylates. The green color of the urine is due to indican 



DENGUE 205 

and pyrocatechin. Binz believes that the salicylates may induce 
abortion. 

5. Alimentary. — Vomiting (v. s.) and diarrhoea may result from 
salicylate treatment. 

Diagnostic Therapy. — Senator claimed that sodium salicylate is 
specific in true rheumatism and inert in pseudorheumatism. Though 
the general truth of this statement is acknowledged, its application 
is not absolute. Salicylates are of some value in the arthritic type of 
grippe. They usually are useless in the gonorrhceal, syphilitic, tuber- 
culous, septic, scarlatinal, and other arthritides. 

Convalescence. — Absolute rest must be enforced for two to four 
weeks to save the heart. 



DENGUE. 

Definition. — An acute specific infection, occurring chiefly in tropical 
and subtropical countries, extremely contagious, and characterized by 
fever, an initial prodromal eruption, violent articular and muscular 
pains, and a secondary polymorphous eruption. 

Etiology and Epidemiology. — The actual cause is uncertain. A 
small diplococcus or bacillus resembling the Bacillus influenza? has 
been described. Graham found, in the blood-cells, an organism re- 
sembling the Plasmodium malaria?, but small and unpigmented. For 
this reason infection has been connected with mosquito-bites. Eberle 
describes a "plasmeba." The disease is very contagious and seems 
disseminated less by direct than indirect infection, e. g., by fomites, 
bites, etc. It is carried by pilgrims, sailors, and emigrants. The dis- 
ease spreads with remarkable rapidity and infects large numbers of 
people. Its home is in the tropical and subtropical zones and it pre- 
vails chiefly in the hot months. It has invaded Europe, Asiatic Turkey, 
South America and the United States. It is remarkable that the coast 
ports are alone invaded. It very seldom reaches inland, and even in 
regions where the disease prevails endemically, closely contiguous in- 
land towns and higher places are exempt. Unhygienic conditions pro- 
mote its development. In the first Philadelphia epidemic it was called 
"Front Street Fever," on account of the squalid condition of the 
houses along the river front. The first epidemic, in 1779, in Java, was 
described by Brylon, and Benjamin Rush wrote of the Philadelphia 
epidemic in 1780. The chief later epidemics or pandemics occurred 
in 1818, 1824-1828 (reaching Savannah and New Orleans), 1830- 
1870 (again reaching America, and seen even as far north as Ohio), 
1876 (Virginia), 1889, 1890, 1895-1897. The morbidity is enormous 
but the mortality is strikingly inconspicuous. Epidemics last two to 
five months. No immunity is conferred by one attack and two, three 
or even four, infections have been observed. 

Symptoms. — After an incubation of one to two days, or some- 
times a little longer, the disease begins suddenly. 



206 THE SPECIFIC IXFECTIOXS 

1. Febrile Stage. — The fever rises quickly to 102°, 104° or even 
107°, usually with a chill, severe frontal or orbital headache, sudden 
and intense pains in the back and limbs, which incapacitate the 
patient while walking and which involve especially the knees. The 
names "breakbone fever/' first mentioned in Rush's description, and 
"dandy fever," given because of the mincing gait which results, bring 
out this salient feature. Dengue is thought by some to originate from 
the Spanish for "dandy." The joints are usually sicollen (pseudorheu- 
matism), and many of them, both large and small, are involved one 
after another. The muscles are often painful and the skin is some- 
times hypersesthetic. The pulse averages 100. The face is suffused 
and swollen, the conjunctivae are injected, the flow of tears is increased, 
and in some cases there is coryza. Total anorexia, foul breath, coated 
tongue, and great thirst, develop; vomiting is occasional and constipa- 
tion the rule. The premonitory rash, usually hypersemic, is of short 
duration. It may last but one to five hours, and is frequently absent. 
The urine is febrile. Prostration may be marked, and, in some cases, 
severe delirium, convulsions, and coma may develop. This stage lasts 
three days ("three-day fever") and ends with profuse sweating. 
Fever is absent in the lightest cases. 

2. Exanthematous Stage. — This stage begins on the fourth day. 
The eruption occurs chiefly on the face, hands, forearms and chest, 
and is decidedly polymorphous. It has been described as scarlatini- 
form, morbilliform, urticarial, erysipelatoid, lichen-like, vesicular, or 
even pustular. It is present in 60 to 100 per cent, of the cases. It is 
evanescent, lasts two to three days, and is followed by fine desquama- 
tion and by intense itching, sometimes by falling of the hair, and by 
cutaneous hyperesthesia. The throat is sometimes red or even in- 
flamed, and occasionally lymph-gland enlargement, parotitis and orch- 
itis occur. The fever in this stage may be elevated, may be absent, 
or subnormal temperature be noted. The pain often recurs. Herpes, 
splenic tumor, otitis, albuminuria and leukocytosis are absent. Leuko- 
penia is persistent. 

3. Convalescence. — Convalescence begins in five to seven davs, 
after a crisis or lysis, and is very tardy. There is great prostration, 
gastric uneasiness, insomnia, emaciation, and anaemia, all of which 
are remarkable after such a short disease. In no other disease of equal 
duration is such marked constitutional disturbance noted. 

Complications and Sequels. — These are great rarities. Cutaneous 
or gastric hemorrhage, neuralgia, endocarditis, pericarditis, nephritis, 
pneumonia, pleurisy, oedema or ulcers, rarely develop. 

Prognosis. — Death is rare, though the morbidity is enormous. The 
highest recorded death-rate was \ of 1 per cent. One death occurred 
in 7,435 cases in the Anglo-Indian army (1872), and 10 deaths in 
100,000 cases occurred in Smyrna. Relapse may occur in one to two 
weeks. 

Diagnosis. — The geography and the presence of an epidemic are 
suggestive. The exanthemata, rheumatism, insolation, yellow fever 



CHOLERA ASIATIC A 207 

(q. v.) and epidemic erythema exudativum multiforme may be suggested. 
Influenza is differentiated by its epidemic-pandemic incidence, its 
occurrence in all climates, seasons and locations (inland as well as 
on seaboard), its more frequent direct infection, the more general 
immunity conferred, the higher coincident mortality (pneumonia and 
tuberculosis), its more frequent respiratory catarrh and lung compli- 
cations, its more severe nervous, intestinal and cardiac symptoms, 
and the greater frequency of herpes, splenic tumor, otitis media, and 
albuminuria. In the rare cases of acrodynia, observed in France, 
Belgium, Turkey, Persia, and Mexico, Scheube gives the following 
differential points : (1) digestive disturbance; (2) facial swelling; (3) 
pains in the extremities, sometimes with anaesthesia of the soles; (4) 
spastic symptoms; (5) afebrile course; (6) erythema multiforme. 

Treatment. — Isolation and quarantine are necessary. Pain is the 
prominent indication, for which antipyrin and salicylates serve fairly 
well, though they are much inferior to opium. 



CHOLERA ASIATICA. 

Definition. — A specific infection caused by Koch's comma bacillus. 
It is chiefly disseminated by drinking-water, is characterized clinically 
by vomiting, severe purging, and by such symptoms as cardiac failure 
and suppression of urine which are due to loss of fluids and to toxaemia. 

History. — The name has been used since the time of Hippocrates, 
Galen and Celsus, but apparently not for Asiatic cholera. Asiatic 
cholera is said to have existed before Christ, and travelers in India 
in the sixteenth century spoke of it. Its first European invasion was 
in 1817, from which time our knowledge of cholera dates. Other epi- 
demics have occurred in 1826, 1832, 1847-1855, 1865-1867, 1873, 
1881-1884, and 1892-1894. Cholera visited America in 1832-1835, 
1836, 1848, 1849, 1854, 1865, 1867, and 1873. This was the last epi- 
demic though isolated cases have occurred since. 

Bacteriology. — Koch, while studying cholera in Egypt and India, 
in 1883-1884, discovered the specific organism in the faeces during life 
and in the bowel at autopsy. The comma bacillus is 1 to 1.5 fj. long 
and half as wide; is smaller than the tubercle bacillus, but more plump 
and curved; is motile and flagellated (Loeffler). Gaffky (1887) first 
obtained pure growths on various media. In cultures its form varies, 
being sometimes S-shaped, and thread- or spirillum-like. The comma 
bacillus is found in the stools and in the intestines, usually in pure 
cultures. After several days it may be found in the bowel wall, though 
rarely in the stomach or vomitus. It usually disappears from the 
movements after six to eleven days and very rarely reaches the blood 
or viscera. 

Etiology. — In its dissemination and contagion, cholera resembles 
typhoid rather than the exanthemata, i. e., infection is less direct 
than indirect. Attendance on cholera patients is not dangerous if 



208 THE SPECIFIC IXFECTIOXS 

the hands are kept clean. The germ is very susceptible to boiling, 
to acids, to ordinary antiseptics, to drying, and to the presence of 
saprophytes in sewers and water. There is little risk of aerial dis- 
semination, though flies may carry infection. Koch early maintained 
that cholera was conveyed bv water contaminaticm. He found the 
cholera vibrios in a water-tank in Calcutta from which infection was 
clearly traced. Fraenkel, von Ermingen, Biernacki, Lubarsch, Loef- 
fler, and others, found it in flowing and stagnant water. Pettenkofer 
vigorously objected to Koch's teaching and insisted that individual 
and local disposition was more essential. He even swallowed pure 
cultures, and luckily escaped infection. It is well known that cholera 
vibrios may be found in the movements without the existence of 
cholera symptoms, just as diphtheria bacilli may be found in healthy- 
throats. The normal acid of the stomach protects the individual and 
animals are infected experimentally only when the gastric acidity is 
neutralized and peristalsis is arrested by opium. Nevertheless, the 
terrible Hamburg epidemic (1892-1894) amounted, as Koch said, to 
a demonstration of almost laboratory exactness. The disease devel- 
oped "explosively." On August 16 there was one case; by August 
27 there were 1,000 deaths, and September 3, there were 10,000 cases 
and 4,300 deaths. The total mortality was over 8,300. The Hamburg 
drinking water came unfiltered from the Elbe River, which was then 
at a low level, the weather being hot. The germ was found in this 
supply. Altona and Wandsbeck, which are parts of Hamburg, had 
a supply of good water, and practically escaped. That part of Ham- 
burg which used Altona water was exempt. Instances might be 
multiplied. The cholera germ is difficult to find in water because it 
is so easily overgrown by saprophytes. 

Infection by ice, by milk, by green lettuce, by flies, or in the labora- 
tory, is less common. The washing of infected linen is particularly 
dangerous to washerwomen. In India, hundreds of thousands of pil- 
grims drink the "holy water" of the Ganges, in which they also bathe 
and defecate. Similar infections occur in the pilgrimages to Mecca. 
In former years the caravans carried infection from India through 
Persia and Afghanistan to Russia, which was also the route of dissemi- 
nation in 1892. Ships from the Orient are extremely dangerous. 

Individual Predisposition. — Decrease of physiological resistance in- 
creases the risk of infection. Acute and chronic alcoholism, the use 
of strong purgatives, dyspepsia, overexertion, poor blood, lack of 
hygienic conditions, and debilitating diseases are therefore predispos- 
ing factors. By counting the mortality in a cholera-stricken com- 
munity for a few years, it can be seen that the total death-rate is not 
increased, which means that weakly persons succumb to cholera and 
that later epidemics of other diseases have a diminished prey. 

Epidemics involve a smaller percentage of the people in large than 
in small cities, but they last for months in large cities and usually 
only for weeks in small towns. Epidemics end with a lessening mor- 
tality, and both their ending and the lessened mortality are probably 



CHOLERA ASIATICA 209 

best explained by the decreasing virulence of the germ. Warm weather 
tends to increase epidemics, and they are usually checked by frost. 
Nevertheless, Russia's severest epidemic occurred in the winter time. 
Symptoms. — After an incubation of two or three days (one to eight, 
possibly fourteen days), the disease develops with varying virulence. 
The bacilli are found in the stools of some healthy persons. Several 
stages are usually described. These may be presented, as they also 
correspond to clinical types of different severity. 

1. Prodromal Diarrhoea. — The stools contain the comma bacillus, 
are thin and normal in color, are voided without pain or tenesmus, 
and sometimes produce only moderate depression or malaise. The 
trouble may cease here, when we speak of cholera diarrhoea, or it 
may pass into the choleraic stage. 

2. Choleraic Stage. — This may usher in the disease or follow the 
first stage. The stools, at first yellow and voided frequently, become 
colorless because the bile pigment is diluted and decreased, and be- 
come thin, — the ominous "rice-water" stools. Diarrhoea usually 
comes on for the first time at night. The stools may number twenty 
or thirty and a pint to five quarts (500 to 5,000 c.c.) are voided daily. 
They have a fetid, not a fecal odor, and contain 98 to 99 per cent, 
water, some salts, and a trace of albumin. In the evacuations are 
seen flocculi which are made up of comma bacilli, leukocytes, epi- 
thelial cells or shreds, detritus, and sometimes a few red cells. There 
is often gurgling, although little gas is voided. Much fluid is thus 
lost to the circulating blood, and this causes some of the following 
symptoms: the abdomen is flat, usually neither tender nor painful, 
and fluid may be percussed in the bowels. Vomiting is frequent, but 
usually follows the diarrhoea. It is painless, although exhausting, 
and is thin, and profuse, even to three quarts daily. Sometimes 
Koch's bacillus is found, or again either urea or its decomposed pro- 
duct (carbonate of ammonia) may be found when ursemia exists. The 
skin early shows the lack of fluid; it becomes shrunken, lax, wrinkled, 
and when pinched, its folds disappear but slowly. The nose becomes 
small and pointed, the eyes hollowed, and the malar bones jut out 
prominently (fades cholerica) ; the extremities, nose, and ears become 
cold and cyanotic, and grayish-blue rings develop beneath the sunken 
eyes. If pleurisy or dropsy are present they are rapidly absorbed. 
The secretions such as the saliva and urine become lessened and dis- 
appear, though nursing mothers may sometimes continue to secrete 
milk. The loss of fluid occasions distressing thirst and muscle cramps, 
especially in the calves of the legs, but also in other muscles, which 
are found dry at autopsy. The immense transudation into the bowel 
has other effects; it concentrates the blood, whose cells and haemoglobin 
rise; the red cells may total six to eight millions and the serum has 
a specific gravity of 1,040 or even 1,070 (1,028 being the normal). 
The heart tones become weak and the pulse rises to 100, because the 
body cannot lose 10 per cent, of its fluid without injury. The heart 
has not enough blood upon which to contract and the blood is viscid; 



210 THE SPECIFIC INFECTIONS 

the heart also suffers reflexly, as it does in intestinal incarceration, 
and degenerates from absorption of toxins (soluble substances from 
the bacilli). The difficulty in oxygenation increases the breathing to 
thirty or forty, and occasions precordial and epigastric anxiety. The 
vox cholerica is due to the dry larynx and weak muscles. The reflexes 
are decreased or absent, the pupils tardy; the sensorium is normal, 
although exhaustion, apathy, and vertigo are usual. The urine con- 
tains albumin and casts which are largely hyaline. While the external 
parts are colder by 5° to 10° or more, the patient feels hot, and the 
internal temperature may be 102° or higher. The loss of weight is 
great (even 0.5 to 1 per cent, hourly!). In some few cases the patient 
dies before diarrhoea develops (cholera sicca). Sometimes these are 
cases incorrectly diagnosticated. Recovery is possible, even with 
these ominous symptoms; reaction may set in, the diarrhoea and 
algidity may lessen, the heart may improve, and erythematous, roseo- 
loifs, urticarial and other rashes may develop. The urine is often 
albuminous, and indican, which was previously absent, may reappear; 
the urea is increased two- or threefold and the ethereal sulphates are 
increased. The symptoms are then chiefly toxic, and probably result 
from absorption of the cholera and other toxins from the intestine (the so- 
called cholera typhoid, — i. e., cholera with a pronounced typhoid state). 

3. Stage of Collapse. — This stage is characterized by asphyxia 
(literally meaning without pulse), paralysis, or algidity. The heart 
tones are inaudible, the radial pulse is imperceptible, the arteries are 
empty, and the veins are full. In days of venesection the blood would 
not drain from the incised veins, and at autopsy little or no blood 
escapes from the vessels. The picture is that of collapse. The skin 
is lead-colored, cyanotic, even violet or purple, and will not vesicate 
after blistering. There is dyspnoea, the expired air is cool, the voice 
gone, the mouth dry, the conjunctiva? dry or opaque, and the lids are 
parted, yet the mind is clear. The evacuations cease. Pericardial 
or pleural rubs may be heard, due to the great viscidity found in all 
the serosa? at necropsy. Very few cases with the symptoms of cholera- 
typhoid react and recover, but most of them die within a few hours, 
or within a day or two. After death the muscles frequently contract, 
to the great terror of observers. The face is distorted, the fingers 
flexed, and the legs drawn up. Post-agonal rise in temperature may 
occur. At autopsy the small intestines are injected, filled with rice- 
water contents, their epithelium or villi are desquamated or necrosed, 
the lymphatic structures are sometimes swollen, reddened and reticu- 
lated. Comma bacilli are found in the stools and intestinal wall, 
and occasionally there is an agonal invagination of the gut. The 
muscles are dry, the spleen small, and the kidneys show a pale cortex 
with great cortical degeneration, especially in the convoluted tubules; 
the renal changes, once attributed to loss of water and disturbed cir- 
culation, are probably toxaemic. 

Complications. — The so-called croupous or diphtheritic enteritis 
is due to the pyogenic cocci. Diphtheroid changes may also be found 



CHOLERA ASIATIC A 211 

in the uterus, vagina and throat. Hemorrhages from mucous or serous 
surfaces, though usually small, may occur. Pneumonia (20 per cent, 
of fatal cases), pleurisy or lung infarct; skin, parotid or other sup- 
purations; icterus, bronchitis, venous thrombosis or post-febrile psy- 
choses, are uncommon. Griesinger's " cholera-typhoid" is the most 
frequent sequel (25 per cent, of cases); nervous complications and 
uraemia are far less common causes than the toxins absorbed late from 
the intestine and operating intensely on the already exhausted, slightly 
degenerated, and anaemic brain. 

Diagnosis. — Diagnosis is usually easy in the presence of an epi- 
demic. The first cases occasion the most difficulty, especially if they 
are light. As already stated, robust individuals may not react to the 
germs found in their stools; simple diarrhoea may result in other 
cases, and only a mild depression may mark some cases known as 
cholerine. On the other hand, aged, weakly, or tuberculous persons 
may succumb to cholera before its characteristic stages develop. In 
clinically suspicious cases, laboratory measures are necessary for diag- 
nosis. The pseudocholera vibrios in the Elbe, Seine, or Danube 
Canal (Vienna) are differentiated with difficulty. The comma bacillus 
is obtained (a) in nearly pure cultures from the stools, especially from 
their shreds; (b) in peptone cultures (1 per cent., with 1 per cent. 
salt) in which the germs are found on the surface in six hours, because 
they rise to obtain oxygen; (c) in 10 per cent, gelatin plates, in which 
they develop in fifteen to twenty hours; (d) the nitrosoindol (cholera- 
red) reaction results on adding sulphuric or hydrochloric acid. It 
was thought that no other bacterium produced both nitrates and 
indol, but the pseudocomma organisms may produce the same reac- 
tion; (e) in animals, in which the cholera germ produces a sudden 
fall of temperature, but this is uncertain; (/) Pfeiffer's test is the 
sole absolute criterion, according to which the blood of animals 
immunized to cholera produces agglutination of the true cholera 
bacillus. 

Cholera nostras produces a similar picture. It is usually less severe, 
though sometimes fatal. In some of these cases the Finckler-Prior 
comma bacillus is found, but in the majority of cases it is absent and 
other microbes are present, such as the colon bacillus, and less often 
the streptococcus, staphylococcus, and a bacillus like the Bacillus 
subtilis; vibrios, proteus and pyocyaneus forms; an encapsulated 
bacillus; Gartner's Bacillus enterides; in meat, anaerobic forms; and 
in mollusks, Zieber's Bacillus piscicidus agilis. It is possible that 
many of our domestic intestinal organisms may become virulent. 
Liebermeister said cholera nostras bears the same relation to cholera 
Asiatica as varicella does to variola, German measles to measles, or 
epidemic icterus to yellow fever. It occurs at the same season. Its 
symptoms differ chiefly in degree, and occasionally, a large percentage 
(even 40) of deaths occur, chiefly in the extremes of life. 

Arsenical poisoning, peritonitis, and intussusception may without 
bacteriological confirmation closely resemble cholera. 



212 THE SPECIFIC INFECTIONS 

Prognosis. — The prognosis is always grave. Cholera ranks next 
after the plague in death-rate, and averages over 50 per cent., prob- 
ably nearer 60 per cent.,, and sometimes SO per cent. : 100,000 to 700,000 
die yearly in India. In IS S3. 2S.000 died in Egypt, 8,605 died in Ham- 
burg, and 800,000 in Russia 1892-1894 . About 45 per cent, of the 
deaths in Hamburg occurred in the first twenty-four hours and 17 
per cent, in forty-eight hours, whence the prognosis is more favorable 
if patients last longer than two days; 85 per cent, die when the stage 
of collapse is reached. Light cases may become severe or the worst 
cases may recover. Unfavorable factors are youth and old age; preg- 
nancy; colorless stools, early frequent movements, early vomiting, 
anuria and low peripheral temperature. 

Treatment. — 1. Prophylaxis. — Quarantine of ships, isolation of 
early cases, thorough disinfection of the stools, soiled linen, etc., and 
special attention to light cases and to any suspicious diarrhoea, are 
most important. In convalescence the stools may remain infective 
for seven weeks Kolle\ Despite the sudden outbreaks in Germany 
in 1S92-1S94. sanitary measures kept the total of deaths at 10,000, 
while in Russia S60,000 died in the same period. Individual prophy- 
laxis concerns the maintenance of the physiological resistance: moder- 
ation in eating and drinking; the boiling of water for drinking and 
washing; the boiling of milk: care in regard to ice; avoidance of 
green fruits or vegetables, and of contamination of food by flies. The 
prophylactic serum of Ferran and Haffkine is valuable. In one series 
of cases the use of the serum reduced the morbidity two-thirds and 
the mortality one-half. 

2. Diarrhoea. — This should be treated by absolute rest in bed, and by 
initial cleansing of the bowels wth calomel and castor oil ; thin gruels 
should be given as a diet; red wine with aromatics. tea, and full 
doses of bismuth and opium should be given. Intestinal antiseptics 
are inert. The diarrhoea, except the early movements, is not easily 
stopped, because absorption is arrested. Cantani advised that 1 or 
2 quarts of 1 per cent, tannic acid solution be given slowly by rectum 
in the hope that it would reach the small intestine, and Griesinger 
advised that larger quantities be given, and that expulsion by the 
rectum be forcibly prevented. The fluid was given until it was vomited, 
apparently with some results. 

3. Vomiting. — Vomiting is intractable. Fluids should not be with- 
held. The stomach may be washed with normal salt solution. Hot 
wine, camphor, coffee, champagne, and hypodermics of morphia are 
also indicated. 

4. Heart. — Failing heart action and renal secretion are sometimes 
helped by a warm bath. Hvpodermatoclysis was recommended by 
Cantani (1865) and intravenous transfusions were employed by Her- 
mann and Latta (1830). Their use was studied during the Hamburg 
epidemic and their employment often increased the heart's force 
and benefited the general condition greatly, at least for a time. The 
results are somewhat better than the mortality (65 to 77 per cent.) 



YELLOW FEVER 213 

would indicate, for they were used in the stage of profound collapse 
(where the death-rate is as high as 85 per cent.) If used earlier the 
results might have been better. The kidney secretion is apparently 
little influenced by this treatment. 

5. Muscles. — Muscular cramps are helped by warm baths, sinap- 
isms, friction, local heat, saline infusions, and morphine, which should 
be given hypodermatically. 

6. Convalescence. — In convalescence, great care is necessary lest 
the diarrhoea return. 

Other symptoms, complications and sequels are treated expectantly. 



YELLOW FEVER. 

Definition. — A specific infection of unknown etiology, which is 
transmitted by the mosquito, is endemic in the American tropics and 
subtropics, and is characterized pathologically by moderate degenera- 
tion, especially of the liver and kidneys, and clinically by a rapidly 
developing fever, by icterus, albuminuria, adynamia, hsematemesis, 
and by other hemorrhages. 

Etiology. — The cause is unknown, although two microorganisms 
have been especially obtained: (1) SanarehTs Bacillus icteroides, which 
is said to be present in the blood, spleen, liver and kidneys, but not 
in the intestine; it is a facultative anaerobe, with rounded ends, 2 to 
4 pt long and half as wide; positive agglutination tests are said to 
have been made; its action is said to be fourfold: (a) steatogenic 
(producing fatty degeneration); (6) congestive and hemorrhagic; (c) 
emetic, and (d) icterogenic. SanarehTs organism is generally con- 
sidered as a contamination. (2) Sternberg's bacillus, resembling the 
influenza germ. While the cause is not known, it is certain that the 
disease is transmitted by the mosquito (Culex or Stegomyia fasciata). 
This was first suspected by Carlos Findlay, in 1881, and the mosquito 
was demonstrated to be the intermediate host by the investigating 
board composed of Walter Reed, James Carroll, A. Argamonte and 
J. W. Lazear. Dr. Carroll recovered from a severe attack, but Dr. 
Lazear died from inoculation. Dr. Myers, of the English Commis- 
sion, also succumbed. The Culex fasciata breeds not only in stagnant 
street pools, but also in cesspools and sewers, whence its special 
danger in unhygienic subtropical and tropical towns. Voluntary 
inoculations by mosquitoes, which twelve days previously had bitten 
yellow-fever patients, in the first three days produced yellow fever 
in non-immunes. Findlay failed to prove his correct suspicion because 
he only allowed the mosquitoes three to six days in which to develop 
the germs which they had absorbed, while twelve days are necessary. 
As in malaria, the tropical foci, the hot summer and autumn seasons, 
the invasion of low altitudes, river courses and coast towns, humidity, 
and exposure to night air, are conditions which promote yellow fever 
because they are suitable to the mosquito. Frost stops infection 



214 THE SPECIFIC INFECTIONS 

because it kills the mosquito. Direct contagion from person to person 
is unlikely. Nurses and physicians are seldom infected from contact 
with yellow-fever patients. Persons going from the City of Mexico 
to Vera Cruz may acquire the disease, but on coming home with it 
they do not cause its dissemination, because the mosquito is not pres- 
ent. Postmortem wounds and direct voluntary inoculations, however, 
have directly communicated the disease. The yellow-fever virus is 
the only virus, infecting man, which passes through fine filters. It 
was thought, until recently, that fomites, clothing, etc., were infective, 
but Reed's committee has experimentally exploded this theory. Volun- 
teers remained in rooms occupied by yellow-fever patients and slept 
in their soiled linen without contracting the disease. 

Predisposition. — The lighter races are more prone to infection. 
The value of acclimatization has been overestimated, and it is thought 
that immunes are merely those who have had light and unrecognized 
infections. Most cases occur in males between twenty and forty years 
of age. Yellow fever is kept alive in endemic foci by mild cases, espe- 
cially among the Creole children. 

Foci and Epidemiology. — The two prominent homes of yellow fever 
are (1) Mexico, the Antilles, Mexican Gulf and Caribbean Sea; and 
(2) Africa, from Senegal, through Sierra Leone, to the Gold Coast. 
The first clear description of yellow fever, according to Sodre and 
Couto, was in 1686, but certainly yellow fever was known before the 
discovery of America. It reached this country possibly in the six- 
teenth century and has extended as far north on the coast as Boston 
and on the Mississippi River as far as St. Louis. It has reached Quebec 
and Chicago. In Philadelphia (1793, 1797-1798), 4,041 died in a 
year; in New York, 2,080; and in -New Orleans, in 1853, 8,000 died. 
Epidemics occurred also in 1802, 1805, 1853, 1867, 1873, 1878, and to 
a slight degree in 1897-1899; New Orleans was visited severely in 
1905; there were about 9,000 cases and 1,000 deaths. Europe is 
seldom, but South America is frequently, invaded. 

General Clinical Description. — Incubation. — The incubation aver- 
ages three or four days. Prodromal symptoms are not infrequent and 
last less than a day. They may be malaise, fatigue, headache, dyspep- 
sia, colic, or other indistinctive symptoms. The disease is often 
divided into stages, not all of which are always present: 

Stage I. — The stage of congestion begins (a) with some headache, 
frontal, supraorbital or retroocular, the earliest and most prominent 
symptom; (b) sometimes with a chill; (c) with flushed face; the con- 
junctivae are injected and sometimes icteric even at this stage; the 
eyes are sensitive to light, the lids somewhat puffed up and the expres- 
sion is a mixture of pain, restlessness and confusion, comparable to 
the alcoholic facies; (d) with backache, and pains radiating into the 
calves of the legs; (e) with fever rising to 104° or more; and (/) with 
a full, tense pulse of 100 to 110. 

The tongue is usually clean or slightly coated dorsally, and its tip 
and edges are red. The urine is febrile and very early albuminous. 



YELLOW FEVER 215 

The skin is intensely red and dry. The epigastrium is tender early 
in the disease and there is marked gastric irritability and intolerance 
of food, water and medicine. This stage lasts two days or somewhat 
longer. 

Stage II. — The remission stage, stage of calm, or deceptive stage, 
occurs in some cases and is so-called because of later severe symptoms 
following this remission. The fever may fall nearly to normal or to 
subnormal; the pulse falls to 80 or 90, and pain and hyperesthesia 
remit. Slight jaundice may now be first apparent. 

Stage III. — The Reaction Stage. — Slight temperature, the " black 
vomit" (vomito negro) of blood, hemorrhage into the nose, intestines, 
uterus or skin, hiccough, epigastric pain and tenderness, liver enlarge- 
ment, and icterus of the skin and accessible mucosae usually mark 
this period. The urine becomes scant and is laden with bile pigment, 
or its secretion is suppressed; the pulse becomes weaker, and such 
nervous symptoms as insomnia, prostration and restlessness may 
appear. 

Various issues are henceforth possible: (a) Gradual amelioration; 
(6) fatal anuria; (c) profuse hemorrhages; especially from the ali- 
mentary mucosa, which usually end in fatal collapse, and rarely in 
recovery; (d) profound icterus, which results in adynamic phenomena 
and usually in death, though recovery is possible, and (e) death, with 
pronounced cardiac insufficiency. 

Special forms of yellow fever are described by Soude and Couto 
which vary with the intensity of infection and of special visceral in- 
volvement. (A). Variations in intensity include (1) light, abortive, 
ambulatory, atypical forms, especially in children; (2) the usual severe 
forms, and (3) the foudroyant type, which is rapidly lethal in twenty- 
four to forty-eight hours. (B). Visceral forms: (1) The hepatic type, 
which is slow, with two weeks of the status typhosus, often with nor- 
mal temperature an*d sometimes with hemorrhages; (2) the uremic 
type, often with early death; (3) the hemorrhagic; (4) the cardiac; 
and (5) nervous or atactic type. 

Special Symptomatology.— 1. Fever. — The fever is neither cyclic 
nor diagnostic, though Sternberg considers that there is a single febrile 
paroxysm of two to seven or eight days. It is usually highest in the 
first stage, and reaches an average of 104° (though sometimes even 
reaching 108°). It may fall on the second or third day to nearly nor- 
mal in benign cases or in the ominous uremic type. High fever on 
or after the second day (second stage) is a poor prognostic, and is 
sometimes due to secondary infection with the pyogenic cocci, or the 
typhoid or colon bacillus. In the second stage the fever is usually 
between 99° and 100°, and may rise in the third stage. A high post- 
mortem rise is frequent. In convalescence, the temperature, aside 
from complications, is always subnormal. 

2. Nervous Symptoms. — Nervous symptoms are often absent in 
both benign and malignant cases. Insomnia and headache are com- 
mon in the congestive period. Delirium is infrequent, and in SO per 



216 THE SPECIFIC IXFECTIOXS 

cent, of the cases, is uraemic rather than purely toxaemic. Atactic symp- 
toms are far more common in children than in adults although they 
may develop in alcoholics and in the debilitated. In children, the 
status typhosus or meningo-encephalitic symptoms (convulsions, even 
unequal pupils, Cheyne-Stokes breathing, and coma) are possible. 
Pathologically, few changes are found except the slight degenerations 
common to the febrile stage, punctate hemorrhage (mostly agonal), 
or bile-tinging. 

3. Circulatory Symptoms. — (a) The pulse in the congestive stage 
is usually 100 to 130 and is tense from increased blood pressure; on 
the third day, 90 to 100 (even 70 to 80); in the second stage it is still 
lower in benign and more rapid in severe cases (110 to 140), is small, 
and the manometer shows lowered arterial tension; in convalescence 
it is usually slow (50 to 60, or even 30). Faget, of New Orleans, em- 
phasized the slowing of the pulse with maintenance of the fever, 
which he and others consider almost pathognomonic, (b) In severe 
forms the first tone over the apex of the heart becomes weak and is 
finally lost. The same is true of the second tone. The heart action 
is rarely irregular or intermittent. Embryocardia is found in severe 
cardiac types. In the second or third stage, cardiac dilatation is com- 
mon (in 70 per cent, of autopsies). Cardiac insufficiency may develop 
early or late. These cardiac signs are due to cloudy and fatty myo- 
cardial degeneration; pericardial and endocardial ecchymoses are 
frequent. Cardiac action is exaggerated when uraemia is present. 
Endocarditis, pericarditis and acute aortitis are infrequent complica- 
tions, (c) There may be some anaemia, but often there is none. The 
white cells are decreased in proportion to the severity of infection. 
The polynuclears are relatively increased. 

4. Respiratory Symptoms. — Respiratory symptoms, such as dyspnoea, 
may be due to intercurrent inflammation or more often to cardiac or 
renal complications. ♦ 

5. Digestive Tract. — Severe hiccough is attributed to irritation of 
the phrenic nerve by distention of the stomach or by enlargement of 
the liver. Epigastric pain, tenderness and anxiety may be sympto- 
matic of cardiac distress, premonitory of the black vomiting, or indica- 
tive of disturbed circulation in the medulla, which is expressed in the 
endings of the vagus. 

6. Icterus (Yellow Fever, Typhus Icteroides). — Jaundice may ap- 
pear early, but usually develops on the third to the fifth day. It is 
frequently absent in children, or in cases of early death from uraemia 
or from nervous symptoms. According to Feraud, it is absent in 50 
per cent, of cases which recover. The explanation for this is an open 
question. Feraud distinguishes two forms (a) the early, lighter jaund- 
ice, due to blood pigment, and (b) the later and more severe type due 
to bile pigments. Sodre declares that the yellow-fever liver cannot 
produce bile pigments. 

7. Liver. — The liver is slightly enlarged and is tender. Patho- 
logically, its color is light, and it has a cooked appearance. The left 



YELLOW FEVER 217 

lobe may reach the spleen. On section, it is oily, fatty, anaemic, and 
under the lens, shows fatty degeneration, disorder, and deformation 
of the liver cells. 

8. Urine. — The urine is early febrile, is sometimes scanty, and shows 
decreased urea, uric acid, chlorides and phosphates. Albuminuria is 
an important finding and occurs in 88 per cent, of cases in the first 
three days. Leucin and the bile pigments are common. Indicanuria 
is very infrequent. Casts are common. The kidneys, anatomically, 
are normal in size, rather pale or yellowish, and, microscopically, show 
great fatty degeneration of the tubules, which in severe cases are 
actually choked by desquamated epithelium and casts. The glomeruli 
show remarkably few changes. Anuria is due to these changes and 
to lowered blood pressure; it is fatal in 97 per cent, of cases. Ur&mia 
causes 33 per cent, of the fatalities; it is marked by delirium, nervous- 
ness, restlessness, twitching or convulsions, by decreased or suppressed 
urine, by rapid, slow, forced, irregular, labored, or Cheyne-Stokes 
breathing, and by tense pulse. Death in coma may occur as early as 
the third day. Uraemia and anuria are rare in children. 

9. Hemorrhages. — These may occur anywhere. They are most 
frequent in (a) the alimentary tract, (b) the nose, and (c) the uterus. 
They result from fatty degeneration, undue permeability, or actual 
rupture of the bloodvessels, (a) Alimentary tract. Hemorrhages 
may occur from the mouth, tongue, lips, stomach, or intestine. The 
black vomit is gradually transuded blood altered by the gastric acid; 
it most often occurs on the fourth to the sixth day; it is the ordinary 
"coffee grounds" vomit or is ink-like; the stomach, at autopsy, shows 
the black contents, congestion, or even dark discoloration, epithelial 
desquamation and fatty change in the muscularis. Hemorrhage from 
the small intestine is almost equally frequent, (b) Epistaxis may 
occur early or late, is often profuse, and sometimes fatal, (c) Uterine 
hemorrhages are severe, especially at the menstrual periods, and in 
pregnant women cause abortion or premature delivery. Less frequent 
are (d) skin petechia?, which are found sometimes in large plaques or 
hypostatic ecchymoses, clinically and at postmortem; (e) muscular 
hemorrhages which are painful, often large, and which sometimes 
suppurate. (/) Hemorrhage in other mucosae (larynx, urethra, and 
eye), the serosae (pleurae, endocardium, or meninges), or in the viscera 
(brain, medulla, and lungs). 

Complications and Sequelae. — These include (1) secondary infec- 
tions with the pneumococcus, pyogenic cocci, or the colon bacillus, 
such as endocarditis, pericarditis, pneumonia, erysipelas, parotitis, 
arthritis, suppuration, and gangrene. (2) Coincident typhoid, malaria, 
influenza, and insolation. (3) Post-febrile psychoses. 

Diagnosis. — The diagnosis is usually easy from (1) the flushed, 
semi-intoxicated facies; (2) icterus; (3) the almost invariable and 
early albuminuria — the most valuable finding in doubtful cases; (4) 
black vomit, gastric intolerance, and epigastric uneasiness; (5) other 
hemorrhages, and (6) the slow pulse, which is absent in some severe, 



218 THE SPECIFIC INFECTIONS 

but therefore clear, cases. Dengue lacks these features. Pernicious 
malaria, with icterus, is distinguished by the blood findings, the enlarge- 
ment of the spleen (always absent in yellow fever), the infrequency of 
early icterus, albuminuria and hemorrhages (except hematuria). 
This form of malaria is rare in the cities, whence the constant sugges- 
tion of yellow fever, when more than sporadic cases are reported. 
Weil's disease (infectious jaundice), and acute yellow atrophy of the 
liver are usually readily distinguished. 

Prognosis. — The mortality of epidemics varies from 10 per cent, to 
85 per cent. The average death-rate is about 30 per cent. The mean 
death-rate, according to age, is 33 per cent, (one to three years), 14 
per cent, (four to eighteen years), and 37 per cent, (nineteen to forty 
years). Unfavorable events are the early development of the third 
stage, hepatic, renal, or cardiac insufficiency, the typhoid state, diffuse 
hemorrhages, combination of special types (cardiac plus renal, or 
hepatic plus renal), high fever with hepatic symptoms, and hemor- 
rhages. 

Treatment. — I. Prophylaxis. — Disinfection of the fomites is now 
less important than the question of the mosquito. Probably no greater 
triumph of hygiene exists than the stamping out of yellow fever since 
the American occupation of Havana. It illustrates not only the 
efficiency of the investigating scientific commission, but also the pos- 
sibilities of medicine in administrative capacity with unlimited dis- 
cretionary power. In Havana the average death-rate was 500 yearly, 
until Gorgas cut it down to nil. The patient should be isolated, not 
to prevent direct personal contagion but to keep the Culex fasciata 
from the infected person. Healthy individuals should be kept from 
infection by the mosquito by the same measures that are employed 
in malaria, e. g., screens, and extermination of breeding foci. The 
Culex fasciata is found outside the habitual yellow-fever foci, and after 
biting patients from abroad, may inoculate other persons. Infected 
insects, too, may be carried by ships. 

II. Symptomatic Treatment. — (a) In the first stage, fluidextractum 
aconiti, tt£. iij, sodium salicylat., gr. xx, and antipyrin, gr. x, may be 
given every two to four hours for a few doses, until the congestion and 
pains are relieved. Coal-tar products are not to be employed when 
depression exists. Fractional doses of calomel, gr. \ every hour for 
five doses, should be given and followed by two or three ounces of 
castor oil. Overmedication is particularly to be avoided because of 
the frequent gastric irritability, and feeding by rectum is often indi- 
cated. Early or violent cerebral, ursemic, or pulmonary symptoms are 
sometimes treated by phlebotomy, (b) In the last stage, the black 
vomit contraindicates any fluid, food, or medication by mouth; warm 
peptonized milk and normal salt solution should be given by rectum; 
morphine, when the patient is in this condition, is dangerous, as is the 
perch] oride of iron, when given by mouth, (c) In cardiac insufficiency, 
digitalis is especially good, and it is apparently beneficial to the patient 
even when cardiac failure is absent; saline solution, by rectum or sub- 



THE PLAGUE 219 

cutaneously, produces better results than intravenous transfusions. 
The patient must be kept absolutely quiet, (d) Uroemic symptoms 
are treated in much the same way. Much water should be given, 
chiefly by the bowel, (e) Nervous manifestations necessitate cool 
spongings, bromides, morphine, and hyoscine, as in Typhoid. (/) 
Vomiting (see Typhoid) is relieved most efficaciously by chopped ice. 



THE PLAGUE. 

Definition. — The pest, or bubonic plague, is a specific acute infec- 
tion caused by the Bacillus pestis and characterized by a pronounced 
typhoid state, fever, buboes and carbuncles, very frequently by sep- 
ticaemia (pesticsemia), and by extremely high mortality. 

History. — The first clear accounts date from the times of Trajan, 
in the second century, and of Justinian, in the year 542. The plague 
was important among the pestilences of the middle ages. In the four- 
teenth century the " black death" swept over Europe with a mortality 
of 25,000,000 (one-quarter of the world's population). It appeared 
from time to time in the sixteenth and seventeenth centuries, but in 
the eighteenth century it withdrew southeast, and disappeared from 
Europe until the small Russian epidemic in 1878-1879. Egypt was 
the early focus for African epidemics, and European epidemics started 
from Turkey. Syria was the leading Asiatic focus, thirteen epidemics 
occurring between 1773 and 1843. The present Oriental focus seems 
to be Southern Thibet, whence India and China have been invaded 
thirty times between 1823 and 1897. Uganda is considered a perma- 
nent plague home by Koch; plague is endemic in Asia near Mecca, 
in Mesopotamia and in Siberia. In 1899-1900, New York, San Fran- 
cisco, Glasgow, Cape Town, South America and Australia were 
visited. Epidemics appear, reach their maximum, and decline at 
nearly the same time each year. The theory that the virus remains 
permanently in the soil has many supporters. 

Etiology. — The Bacillus pestis was found by Yersin, in 1894, and 
at the same time Kitasato found a similar, possibly an identical, bacil- 
lus. Its ends are rounded and stain deeply; its sides are somewhat 
convex; it measures \\ to If by J to f p. and is encapsulated. It is 
polymorphous, and appears with equal frequency as rods or as diplo- 
bacilli. Atypical forms are oval, ovoid, annular, chain-, thread-, or 
branch-like. Other degenerative or involution forms are the pyri- 
form, biscuit, comma-shaped, or spermatozoid. Though it is most 
often outside of the cells, it may appear in them. It contains no spores 
nor flagella. It is found in all organs, in the spleen, the lungs and 
tonsils; in the sputum, the urine and faeces; and in the bubo and car- 
buncles. Its cultures are typical, and superficial, and have bulging, 
wall-like edges. It stains with ordinary stains, — e. g., alkaline methy- 
lene blue, etc. — but not by Gram's method. It is readily killed by 
heat, sunlight, desiccation, antiseptics, and is often overgrown by second- 



220 THE SPECIFIC IXFECTIOXS 

ary infection. It lives, at the most, for three to four weeks in buried 
bodies, but may persist much longer (v.i.) in the saliva, sputum, 
urine or faeces of convalescents. 

Atrium. — It may enter (1) by the skin, through invisible wounds, 
as does erysipelas; through scratches, or as shown by Albrecht and 
Ghon, through the intact integument. Postmortem infections are 
frequent, even though there is no visible abrasion. Laboratory inocu- 
lation is possible, as was unfortunately demonstrated in the Vienna 
cases, among which was that of Muller, who was then writing his well 
known monograph. Flies, fleas, ants, bed-bugs, etc., may inoculate 
the disease. (2) The accessible mucosa, conjunctivae (experimentally), 
and clinically the nose, tonsils, anus and external genitalia, may be 
primarily infected. The nose and throat are especially frequent points 
of entrance in children, for obvious reasons. (3) The alimentary 
tract affords a possible atrium. (4) The bacillus may cause prim- 
ary plague pneumonia, whence metastatic infections occur. 

Contagion may be direct or indirect, (a) Direct. — Dissemination 
by the sputum of plague pneumonia is most dangerous, for the bacilli 
are scattered by coughing, as shown in Fliigge's experiments in tuber- 
culosis (q.v.). The pest spreads rapidly only when it is of the pneu- 
monic type. The bacilli may penetrate from unruptured carbuncles 
or buboes or scatter from them after their rupture. The urine, the 
faeces, and the milk of nursing women are also dangerous. Direct 
contagion may result from autopsies, from operations, or from nasal 
or urinary hemorrhages, (b) Indirect. — This may result from fomites, 
from bites of animals or insects containing the germ, and, possibly, 
from contaminated water. Epidemics among rats may precede human 
epidemics. In Canton, 35,000 dead rats were found in one district. 
The disease may also exist among apes, cats, mice, and other animals. 
Infection by flies, fleas, etc., is certainly possible, and Simond con- 
sidered the rat-flea particularly responsible, though the parasites of 
animals seldom attack man. Flies may convey infection from the urine 
or faeces of infected rats. The bacillus produces virulent toxins. 

Symptoms. — -There are two factors in the clinical picture: (a) The 
local changes, such as those in the primary localization (bubo or 
pneumonia), and (b) the successive septicaemia (pesticaemia) and 
toxaemia. The average incubation is five days (two, to seven or ten). 
Occasionally there is transitory prodromal depression, nausea, or 
glandular pain, but usually the onset is very acute, with marked head- 
ache, intense vertigo, severe rigor, sudden fever, and, in children, con- 
vulsions. Early vomiting is quite frequent. There is early glandular 
pain, the prostration is profound, and an early typhoid state develops. 
The fever reaches 104° on the second day, is either continuous or 
remittent, in convalescing cases falls by lysis (fifth to seventh day), 
or may remain high until death. Crisis is seen in light cases 
only. The skin is hot and dry or may be covered with sweat as death 
approaches. Herpes never develops. Skin hemorrhages are frequent. 
They are due to embolism caused by the Bacillus pestis, they occur 



THE PLAGUE 221 

almost always in the agony or shortly before death, and are seen mostly 
in the upper trunk, •arms, head and neck, and sometimes also in the 
muscles and periosteum. Abscesses, phlegmons, gangrene, or bed- 
sores, are not common. 

1. Characteristic Local Finding. — This is the bubo, for the lymph 
glands are more important than in any other infection. The several 
clinical forms of the plague usually described are (a) the bubonic 
type (77.7 per cent.); (b) the septicemic type (14 per cent.); (c) the 
pulmonary type (4.3 per cent.); (d) the carbuncle type (2.5 per cent.); 
(e) mixed infection (1 per cent.), and (/) the ambulatory type (pestis 
minor, 0.5 per cent.), which is considered by Scheube as not plague 
but " climatic bubo/' The figures are from Choksey, of Bombay. 
In the great majority of cases, probably in all except in the pulmonary 
type, the bubo is found very early (90 to 98 per cent.) and local pain, 
tenderness and swelling are present. The primary bubo occurs in 
the external lymph glands in the region of the atrium; it is large, 
very painful and tender, and is attended by great periadenitis, oedema, 
hemorrhage and vesicle formation in the skin. Its size and rapid 
growth are due in part to medullary swelling of the lymph 
glands, but chiefly to hemorrhage, which may spread along the nerves, 
arteries or veins, into which it may break, thus disseminating the 
bacilli. The glands may fuse, and a brawny mass, as large as an egg, 
or a man's fist, results. The glands and surrounding tissues contain 
enormous numbers of bacilli at this stage. The location is inguinal 
(70 per cent.), axillary (20 per cent.), and cervical (10 per cent.).. 
The inguinal and axillary adenitis is more common in males; cervical 
adenitis results in children from infection of nose and throat by dirty 
fingers; the popliteal and epitrochlear glands remain uninfected with 
curious frequency, being involved in but 1 or 2 per cent. Strangely, 
too, the lymph-vessels are usually unaffected, although they are 
sometimes inflamed near the buboes or carbuncles, or around the 
atrium of infection. From the primary bubo (especially when the 
blood is not early infected) the contiguous glands are involved; 
e.g., after the infection of the inguinal glands, the iliac, aortic, medias- 
tinal, subpectoral, infra- and supraclavicular or cervical glands may 
be involved; i.e., infection usually occurs in the direction of the 
lymph-current, but retrograde involvement is possible. On the fourtn 
to the sixth day .necrosis occurs, and on the eighth or ninth day sup- 
puration develops, resulting from mixed infection (33 per cent.), but 
more often (66 per cent.) from the Bacillus pestis alone. Some glands 
may resolve without suppuration. The primary bubo is often incon- 
spicuous and its size has no bearing on the intensity of the disease, 
although cases with marked periadenitis rarely recover. Besides the 
primary bubo and its contiguous lymphatic extension, Albrecht and 
Ghon described the secondary bubo which is infected by the bacilli- 
laden blood current. The bacilli have a remarkable affinity for lymph- 
atic structures and settle in them largely. These hematogenous buboes 
are generally smaller and less tender, painful, cedematous, and hemor- 



222 THE SPECIFIC INFECTIONS 

rhagic, than the primary bubo, and rarely exhibit periadenitis unless 
the clinical course is protracted. They contain the bacilli in numbers, 
as do other lymphatic tissues, such as the mesenteric glands, the 
pharyngeal follicles, the stomach, intestine, and lung. Carbuncles 
result chiefly from pesticasmia, although apparently in some cases 
they are the atrium. They occur in 10 to 15 per cent, of the cases, 
often near the primary bubo. The crowning serous vesicle is rup- 
tured, discharges bacilli, and leaves an ulcer, whose floor is bluish- 
red from hemorrhage, or yellow from swarms of bacilli. A dark 
crust then forms. There is great peripheral infiltration, and the whole 
limb or part of it may become cedematous. These lesions indi- 
cate that the pesticsemic type is less a distinct type than an almost 
regular part of the disease. Cases rarely recover which show bacil- 
lsemia. The blood shows some anaemia and moderate polymor- 
phonuclear leukocytosis. The spleen is increased three to four 
times, is reddish, and is somewhat less soft than it is in typhoid, 
anthrax, or streptococcic infections. Its cut surface is finely gran- 
ular and is slightly glistening. It is infiltrated with white cells 
and bacilli, which are found especially in the innumerable foci 
of minute necrosis. It is usually palpable on the first or second 
day. 

2. Nervous System. — The nervous system suffers few anatomical 
changes except meningeal hemorrhages and brain oedema. Clinically 
the toxsemic nervous "typhoid" symptoms are as prominent as the 
buboes. There is early headache and marked prostration. Vertigo 
is especially notable, causing a drunken, cerebellar gait, and vomiting. 
The delirium is more often dull, dreamy and docile, than active or 
maniacal, though the patient may fight the attendants or run away. 
Motor twitching, tonic or clonic spasms, subsultus, rigidity of the 
neck or spine, and even bulbar symptoms, such as increased pulse and 
respiration, polyphagia or polydipsia, may be suggestive of meningitis, 
which sometimes actually occurs by pesticsemia. Acute ataxia, mye- 
litis, paraplegia, hemiplegia, or isolated neuritis (monoplegia, vagus 
weakness, aphonia, palate paralysis) and other nervous sequels are 
uncommon. Ear symptoms are unusual, but are easily masked by 
the profound typhoid state. Conjunctival hyperemia, sometimes with 
ecchymoses, is so frequent that it is, together with the fever and buboes, 
made one of the cardinal symptoms by Yamagiwa. Iridocyclitis is 
not uncommon. 

3. Circulation. — The circulatory and the nervous changes measure 
the intensity of infection and forecast the prognosis. Possibly there 
is no other cardiac poison as intense as is the plague toxin which 
operates on the medulla and its vagus nucleus. Early in the attack 
the pulse is full and dicrotic, with a rate of 80 to 90. Later, the pulse 
increases to 120, 150, or even 200; the heart tones become muffled; 
tachypncea, great dyspnoea, and all the signs of acute cardiac insuffi- 
ciency develop. In some virulent infections the pulse may remain 
slow. At autopsy the heart is lax, the right ventricle dilated, the myo- 



THE PLAGUE 223 

cardium cloudy, and the serous investment ecch\motic. Endocarditis 
or pericarditis almost never occurs. 

4. Respiratory Tract. — The lymph structures in the larynx, trachea, 
or bronchi are infected by aspiration from tonsillar foci or through 
the blood. Fatal laryngeal oedema may occur. Most important is 
the plague pneumonia, of which there are two varieties, (a) the pri- 
mary, in which the lung is the atrium (or analogue of the primary 
bubo). It was clearly the " black death" of the middle ages (Forbes). 
It was seen in India, in 1838, and became well known in the 
Indo-Chinese epidemic of 1896-1897, when Childe first found the 
Bacillus pestis. The bacillus, if inhaled, causes typical confluent lobar 
pneumonia and salient lymphatic involvement. The bacilli exist in 
hordes in the lung and sputum, and may cause hematogenous buboes 
and carbuncles. The diagnosis is positive only when the sputum 
appears; this is followed by cyanosis, dyspnoea, profuse hemoptysis, 
splenic tumor, pleuritic pains, signs of consolidation, adynamia and 
collapse. Death occurs in 97 per cent, of the cases. (Jb) Secondary 
pneumonia is (i) embolic (Yamagiwa), and occurs with abscess in 
the liver and kidney; it develops as multiple small foci, is difficult to 
diagnosticate surely, though bacilli in the sputum, dyspnoea, and 
pleuritic pain are suggestive, (ii) Aspiration pneumonia usually occurs 
in the lower lobes, its diagnosis is difficult, it follows bubonic disease 
of the tonsil, pharynx or bronchi, and is almost invariably fatal. 

5. Digestive Tract. — A moist, then a dry, tongue, hemorrhage from 
the gums or throat, vomiting and involvement of the tonsils or pharynx, 
are common. There may be ecchymoses in the stomach and intestines, 
hemorrhagic erosions, bacilli in the bloodvessels, and bubonic changes 
in the lymph structures. The latter, generally considered rare, were 
found by Wilm in 20 per cent, of his cases, and mesenteric adenitis in 
60 per cent. Meteorism and diarrhoea sometimes develop. The liver 
is slightly swollen from cloudy and fatty degeneration or from stasis; 
bacilli may be found in the ecchymoses, in the bile, or in the feces. 

6. The Genito-urinary Tract. — The urine is decreased, the specific 
gravity is 1,010 to 1,020, the chlorides are decreased, indicanuria is 
frequent, and moderate albuminuria is very common. Nephritis is 
quite frequent. Anatomically, degeneration, minute focal necrosis, 
and glomerular hemorrhage resulting from capillary embolism of the 
bacilli, are common. Bacilluria occurs in about 30 per cent, of the 
cases. The bacilli have been found in the aborted foetus. Genital 
complications, except uterine bleeding, are rare. 

Diagnosis. — The cardinal signs are the fever, buboes, pesticsemia, 
and the results of examinations by means of cover slips, cultures, agglu- 
tination, and inoculation. Though the finding of bacilli in the blood 
is important in cases without buboes, the cultural results are more 
reliable. The agglutination reaction is not well marked until the 
second week of infection, is seen most advantageously in convalescence, 
and may still be seen for eight weeks or more. A positive test is final, 
though negative results do not exclude plague. 



224 THE SPECIFIC INFECTIONS 

Prognosis. — A patient may become ill in the morning and die 
before night. The average duration of the disease is about a week. 
If the patient should outlive this time, the chances of recovery are 
good. Recurrences are not frequent but have occurred, and the im- 
munity conferred is only relative. Symptoms which are unfavorable, 
are especially marked nervous and cardiac toxaemia, digestive disorder, 
hemorrhages, cervical buboes, tonsillar involvement, and pneumonia. 
The death-rate varies with the epidemic. It is often 80 per cent, and 
sometimes 90 or 95 per cent. It is highest between the fiftieth and 
sixtieth years; next between the thirtieth and fiftieth. In Toulon 
(1721), 77 per cent, of the population had the plague and 62 per cent, 
died — higher percentages than in any other epidemic disease. In 
Canton, 8 per cent. (1894), and in Damaum, 30 per cent, of the popula- 
tion died; 430,500 died in Bombay, from 1896 to 1899. 

Treatment. — 1. Prophylaxis. — The plague patient should be iso- 
lated and carefully covered with netting. Infected houses should be 
isolated, unroofed to admit the sun, fumigated to kill insects and rats, 
and the walls should be washed with antiseptics. Vigorous attacks 
should be made on rats. Ships should be held in quarantine until 
the rats in their holds are killed, the bilge-water disinfected, and all 
clothing fumigated. The sputum may be infective for three months 
and the urine for one and a half months. Carbuncles and buboes 
should be washed with bichloride of mercury and dressed antiseptic- 
ally. Prophylactic inoculation with dead cultures and with serum 
from immunized animals and from convalescent patients, is a measure 
assured of success *(Haffkine, Yersin, Roux and Lustig). 

2. Symptomatic Treatment. — Buboes and carbuncles are most effi- 
caciously treated with dressings of weak bichloride of mercury. Sur- 
gical extirpation may disseminate infection, and injections, into the 
buboes, of carbolic acid, do not stay the septicaemia. Digitalis, alcohol, 
and hydrotherapy are employed as in other toxsemias. Bichloride of 
mercury is well tolerated and has been used freely since it was noted 
that syphilitics under mercurial treatment seemed to withstand the 
disease. 



DYSENTERY. 

Definition. — An acute contagious disease, (a) with varying etiology, 
but caused chiefly by the Amoeba dysenterica and Shiga's Bacillus 
dysenterise; (b) attended anatomically by bowel inflammation (catar- 
rhal, necrotic, or ulcerative) and (c) characterized clinically by colic, 
pain, tenesmus, and frequent muco-bloody passages. 

History. — The name dysentery dates from Hippocrates (480 B. C), 
and the affection is clearly mentioned in the oldest medical script, the 
Papyrus Ebers (1550 B. C), and in the Veda. It has been the 
scourge of armies from the times of the Greco-Persian wars. The 
most severe and wide-spread epidemic occurred in 1847-1856. In 






DYSENTERY 225 

our civil war there were 287,522 cases among the Northern troops. 
Among the English soldiers in India 30 per cent, of the deaths were 
due to dysentery. It prevailed in the recent South African and Span- 
ish-American wars, but was practically absent among the Japanese 
forces (1904-1905). Though essentially a disease of the tropics and 
subtropics, it is frequently observed in temperate zones, especially 
in prisons and in asylums. Lack of hygiene, overcrowding, eating of 
spoiled food or fruits, impure water, and alcoholic or other excesses, 
are predisposing causes. For several decades the disease has decreased 
in Europe and America. 

Classification. — A classification and description of dysentery is most 
difficult, because our knowledge of all its causes is as yet imperfect. 
Two well known forms will be described first, and various indeter- 
minate allied forms afterward. 

I. Shiga's Bacillary Form of Dysentery. — In 1897 Shiga, of Japan, 
described the Bacillus dysenteries as the sole cause of the Japanese epi- 
demic form. His claims are based on these facts: (a) it is always 
found; (6) it occurs in no other affection; (c) its numbers, in a given 
case, correspond to the intensity of the infection; (d) it is found in the 
intestinal wall ; (e) the bacillus and its toxins, when inoculated, produce 
intestinal hemorrhage; (/) there is a specific agglutination which 
occurs in no other disease, increasing in intensity under observation 
and most marked in convalescents; (g) the serum of the immunized 
cases is of prophylactic and therapeutic value; (h) actual inoculations 
in man produce dysentery, as in Strong's inoculation of a criminal 
under sentence of death, and in Flexner's assistant, as well as in acci- 
dental laboratory infections. The bacillus resembles the colon and 
typhoid bacilli in form. It usually occurs singly, but sometimes in 
pairs. It is less motile than the Bacillus typhosus but is flagellated; 
it is a facultative anaerobe, contains no spores, stains readily but not 
by Gram's method, and grows on all media. In gelatin it grows with 
deep, pin-point cultures, is brownish-yellow without liquefaction, 
and has well marked borders; it develops best in glucose agar (gray- 
ish growth along the puncture, without fermentation), or in litmus 
milk (some slight acidification, followed by alkalinization and a brown- 
ish color). Inoculations by mouth succeed, even without first disorder- 
ing digestion. Inoculation intraperitoneally or subcutaneously is 
usually fatal, but sometimes causes colitis. Almost pure cultures are 
obtained from the movements. They are most abundant when the 
lower intestine is greatly involved, and are less in the early stages 
from diarrhceal stools than they are in the later stages from muco- 
bloody stools. When the dejecta become purulent (latest stages), the 
bacillus disappears. It is found in the mesenteric glands, but not in 
the blood, spleen, or liver. Infection is probably carried by contami- 
nated drinking water. Flexner, Barker, Strong, Musgrave and Craig 
have found this type in the Philippines; Kruse found it in Germany, 
Flexner in America (1901); Goodliffe and others also report, it. It 
has been found in Porto Rico. Duval, Bassett, Wollstein and other 

15 



226 THE SPECIFIC INFECTIONS 

clinicians have found it in infantile types. There are three strains 
of the bacillus : (1) The Shiga type, which attacks glucose but not other 
sugars; (2) Flexner-Harris type, which attacks glucose, mannite and 
dextrine but not lactose, and which forms more acid than the Shiga 
type; (3) Hiss-Russell type, which attacks glucose and mannite but 
not lactose or dextrine. The blood of a dysentery subject will aggluti- 
nate all types, but particularly the second. The bacillus constituted 
54 per cent, of Strong's and Musgrave's series of 1,328 cases in the 
Philippines. Epidemics have existed for centuries in Japan, chiefly 
between the months of June and October. In the Philippines, dysen- 
tery prevails at the end of the rainy season. 

Symptoms. — After an incubation of two to eight days, there is a 
sudden onset with fever, reaching 100° to 102° (even 104°), colic, and 
diarrhoea. Pain becomes marked and the simple diarrhceal stools 
soon show mucus, and then bloody mucus or pure blood, which is 
voided with great frequency and severe rectal spasm (tenesmus). 
The passages are small, numbering twenty to sixty or even one hun- 
dred a day, and contain Shiga's bacillus. The rectum may prolapse. 
The urine is scanty. In mild cases the symptoms abate in two to 
three weeks, and the stools become purulent and contain fewer bacilli. 

The symptoms arise from local inflammation and from systemic 
reaction, not to toxins, according to Shiga, but to solution of the bacilli 
themselves in the tissues. In the more severe cases the systemic reac- 
tion is profound, especially when lesions occur in the lower small 
intestine, the absorptive power of which is great. A typhoidal condi- 
tion results, with coated tongue, nervous toxaemia, and weak pulse, 
and death frequently occurs as early as the fourth or seventh day. 
Shiga names this entero-dysentery, as distinguished from the ordinary 
type, colo-dysentery. If the stools become putrid or gangrenous, the 
outlook is hopeless. Ecchymoses on the chest, epigastrium, and inner 
surface of the limbs are quite frequent. Some choleriform cases occur. 
The disease sometimes lasts for weeks or months. Emaciation is 
marked in acute and chronic forms, which is due to diarrhoea, inani- 
tion, pain, and intoxication. 

The symptoms are largely explained by the anatomical findings. 
The bacilli lodge in the small folds and large flexures of the colon and 
sigmoid. Their action is furthered by constipation. The mucosa is 
intensely hyperaemic and shows several degrees of inflammation, which 
varies according to the intensity and duration of the infection. It 
becomes catarrhal, hemorrhagic, diphtheritic, and finally necrotic with 
ulceration. The' rugae are wide and swollen; the entire mucosa is 
swollen, cedematous, thickened, and shows superficial coagulation ne- 
crosis, fibrinous exudation, and cellular infiltration; the submucosa 
is infiltrated and vascular; the muscularis is sometimes infiltrated 
and the serosa is ecchymotic and freshly fibrinous. In marked 
cases the necrotic areas become ulcers, in or between the follicles; 
they have a flat base, occupy chiefly the folds, usually reach only the 
muscularis mucosae, and in intense cases impart to it a sieve-like 



AMCEBIC DYSENTERY 227 

aspect. The swelling may be such as to obliterate the lumen of the 
intestine. Cocci and colon bacilli are in the upper layers but never 
in the lower ones, where we find the Bacillus dysenteric in and around 
the glands. If the small intestine is implicated, the mesenteric glands 
swell. In the virulent cases the gut becomes gangrenous. The spleen 
is never involved. Stenosis may follow cicatrization of the ulcers. 

Diagnosis. — Local rectal disease (syphilis, cancer, or papilloma) may 
possibly be confusing. In contradistinction to amoebic dysentery, it is 
generally acute, with a course of two or three weeks; toxemic symp- 
toms, such as fever, headache and delirium, and hemorrhages, are com- 
mon, because involvement of the small intestine is usual ; anatomically 
the ulcers are flat and are on the folds of the intestine. Amoebic dysen- 
tery is characteristically subacute or chronic. The small intestine less 
frequently suffers (Shiga); liver abscess is common (20 to 33 per cent.), 
and anatomically necrosis begins in the submucosa and produces ulcers 
with undermined edges. Agglutination is similar to that of the Widal 
reaction in typhoid; it occurs in dilutions of 1 to 20 (even 1 to 50, 100, 
or 1,000). Shiga observed that it gradually increased as the disease 
progressed, as Foerster noted in typhoid fever. It may appear on the 
third day, but is usually seen in the second week and most clearly in 
convalescence. It is therefore rather late for diagnostic purposes. 
If it increases while under observation and is marked, it is a good prog- 
nostic, and the converse is true. 

Prognosis.— The prognosis is more favorable in involvement of the 
rectum and sigmoid flexure than when the upper colon or caecum is 
affected. Intoxication is a bad prognostic. The effect of serotherapy 
(v. i.) is another factor. The mortality is high, particularly in Japan, 
where, in 1893, there were 167,300 cases with 25 per cent, mortality, 
and in 1900, 462,000, with 22 per cent, mortality. No immunity is 
conferred. A second attack was observed in 2.7 per cent, and a third 
in 0.3 per cent, in Ogata's collection of 25,279 cases. 

Complications. — These are parotitis or muscle suppuration, which 
are secondary infections occurring in severe cases and in the third 
to the fifth week; ascites in debilitated subjects and beriberi. 



II. Amoebic Dysentery. 

Lambl (1859) and Loesch (1876) discovered an amoeba in the 
bowel movements, but Kartulis, in Egypt, studied over 500 cases and 
found the amceba in them and found the secondary liver abscess. 
Kartulis established his claims for the Amoeba dysenteric on the 
grounds that (a) it was constant in certain forms of dysentery, in the 
ulcers, faeces and liver abscesses; (b) it was inoculable in cats; (c) 
negative results were obtained with other organisms and with the 
amceba which is found in normal faeces. This was confirmed by Koch, 
Hlava, Fenoglio, Quincke, Roos, Pfeiffer, Kovacs, Kruse, Pasquale, 
and others in Europe, and in America first by Osier (1890); the 



228 



THE SPECIFIC INFECTIONS 



Fig. 18. 



important monographs of Councilman and Lafleur, Dock, Simon, 
Musser, Stengel, and Harris soon followed. The home of amoebic 
dysentery is in the tropics, especially in Egypt, India, Formosa, China, 
Arabia and in Italy, where it is endemic and sometimes epidemic. 
Sporadic cases occur everywhere in the temperate zone, especially in 
Germany and in America, where it is the most frequent form. The 
author has seen six cases which were clearly acquired in Chicago. In 
the Philippines it constituted 42 per cent, of the Strong and Musgrave 
series. According to Flexner and Strong, it is more frequent in 
chronic than in acute cases. The amoeba is found in the pus, glairy 
mucus, or blood-tinged mucus of the evacuations. It is round in the 

quiescent stage or irregular from 
protrusion of pseudopodia, partic- 
ularly when the slide is slightly 
warmed. It measures 12 to 30 /jl 
and consists of a hyaline ectoplasm 
and a finely granular endoplasm. 
The minutely granular nucleus 
measures 5 to 7 /*. Besides the 
nucleus one or several vacuoles 
may be seen in the cell. Its glisten- 
ing appearance, size, movement, 
swarming granules, vacuoles, and 
frequent red blood-cell inclusions, 
readily differentiate it from swollen 
epithelia or leukocytes. It stains 
readily. The amoeba probably 
It has been cultivated in pure cultures 




Amoeba coli. (Hallopeau.) 



enters in the food or drink. 
(Wooley and Musgrave). 

Symptoms. — The symptoms of acute amoebic dysentery begin rather 
abruptly with much the same picture as in Shiga's type, although 
the fever is generally lower and shorter, rarely lasts more than two 
or three days, and is sometimes absent. The movements are alkaline, 
pultaceous, fluid, and yellow, at first, and later, mucous and bloody. 
Sometimes in one movement faeces are voided first, followed by mucus 
and blood, or blood-tinged fluid containing amoebae, slightly yellow, 
glairy clumps like swollen sago or frog spawn, pus cells, detritus, and 
sometimes the Charcot-Leyden crystals. The stools may be chocolate- 
colored. Sometimes large masses of necrotic tissue are voided. The 
stools number 5 to 20 or more daily; their odor is fetid when faeces 
are present; they are odorless when only blood or mucus is present; 
and are stinking when gangrene occurs. The repeated and painful 
movements cause straining, sweating, and sometimes syncope. Colic 
and borborygmus are nearly always present; pain is referred to the 
navel; tenderness is usually marked over the sigmoid, colon and fre- 
quently over the caecum, and tenesmus and a burning anal pain mark 
involvement of the lower bowel. The rectum may prolapse and vesical 
symptoms, such as strangury, may appear. The abdomen is some- 



AMCEBIC DYSENTERY 229 

times distended. Very light cases may only show catarrhal move- 
ments, but blood, pus, membrane, or shreds, indicate necrosis and 
ulceration. Severe cases may begin with chills, fever of 103° or 104°, 
vomiting, herpes, and symptoms like those of cholera; e. g., dry tongue, 
depression, 20 to 100 movements daily, leg cramps, scanty urine, fail- 
ing pulse, rapid emaciation from loss of rest and of fluid, and from 
pain. Early death may result. Peracute cases, with chill, high fever, 
great abdominal pain, collapse, and even sudden death, are excep- 
tional, but may result from extensive rapid necrosis or gangrene. In 
the average acute case, the course of one and a half to three weeks, 
or to several weeks, varies with several factors, but especially with 
the individual resistance and the treatment. Perforative peritonitis 
sometimes occurs, as well as profuse exhausting hemorrhages. Light 
cases, if neglected, easily become severe or chronic, and spontaneous 
recovery is quite uncommon. 

Chronic amoebic dysentery may result from the acute form or stage, 
or be subacute (subchronic) from the beginning. The symptoms are 
essentially the same, but less intense. As a rule there is marked, and 
sometimes extreme emaciation, particularly in the tropics. On the 
other hand, some patients maintain their weight and suffer only from 
recurrent diarrhoea every few weeks or months, or from irregular 
moderate intestinal derangement. In the average case the tongue 
is lacquered and red, the abdomen is somewhat distended and tender, 
the lower colon and sigmoid are palpable as a thick cord, and some- 
times mental depression or hypochondriasis is observed. The outcome 
is (1) recovery after two to four months; (2) recurrent attacks for 
months or years; (3) complications, such as liver abscess (20 to 33 
per cent.), especially in the tropics (peritonitis, empyema, or lung 
abscess). Perforative peritonitis, exhausting bowel hemorrhages, brain 
or splenic abscess, pseudorheumatism (Sydenham, Trousseau), myel- 
itis (Gubler, Mitchell), neuritis, and less frequently, endocarditis, 
or chronic nephritis, are other complications; (4) gradually in- 
creasing anaemia, emaciation and death from exhaustion. 

Pathology. — The early changes of the mucosa are catarrh, inflam- 
mation with injection, swelling, and hemorrhage, mostly in the large 
intestine. The essential change is not superficial in the mucosa, but 
in the submucosa, as John Hunter first noted, though Councilman and 
Lafleur first brought out this point clearly. The amoebae enter by the 
tubular glands and reach the submucosa where, by their action alone, 
without bacterial cooperation, they cause cellular accumulations which 
are not leukocytes, but chiefly fibrinous exudation and connective- 
tissue cells. Sometimes the amoebae enter the bloodvessels early and 
pass through them to the submucosa. These foci undergo coagula- 
tion necrosis and slightly elevate the mucosa which at first covers the 
small submucous cavities, but afterward sloughs, and exposes the 
primary grayish-yellow necrosis in the submucosa. When the necrotic 
tissue sloughs out, the dysenteric ulcers are more apparent. They lie, 
according to Kartulis, in the whole of the large intestine (50 per cent. 



230 THE SPECIFIC INFECTIONS 

of cases); in the colon descendens and in the sigmoid flexure (25 per 
cent.); in the caecum, with ascending or descending colon, or in the 
rectum (25 per cent.) ; in the rectum alone (20 per cent.) ; in the csecum 
alone (5 per cent.), and only rarely in the small bowel or in the appen- 
dix; Musgrave found the appendix involved in 7 per cent., the ileum 
in 3.5 per cent., and the entire bowel in 80 per cent., of his series of 200 
cases. The deep ulceration generally exceeds the superficial ulcera- 
tion, and the ulcers in the early stage may communicate with the intes- 
tinal lumen only by fistulous tracts which undermine the apparently 
healthy mucous membrane. Even when the ulcer's opening is large, 
its edges are generally undermined. Ulceration of the solitary follicles 
is less frequent than submucous necrosis. The ulcers may be round, 
serpiginous and are usually discrete. They may penetrate to the mus- 
cularis or to the serosa, which is sometimes perforated, thus causing 
diffuse or localized peritonitis. The peritoneum is often pigmented 
and shows fresh fibrin deposits or local adhesions. Secondary changes 
may include membranous diphtheroid deposits (usually streptococcic), 
diffuse sloughing of entire blocks of the intestinal wall, gangrene, and 
great hyperplasia of the mucosa. In chronic cases the muscularis fre- 
quently thickens, which may greatly narrow the lumen of the intestine. 
The small intestine may atrophy or hypertrophy. Healing ulcers 
produce pigmented stellate scars which sometimes cause stenosis. 
Amoebae have been seen in the mesenteric bloodvessels, by which 
they reach the portal circulation (pylephlebitis, liver abscess). The 
liver shows focal necroses which are probably toxaemic, and, in a large 
percentage, it shows solitary or multiple abscesses. The single, large 
abscess generally develops in the right lobe near the diaphragm or 
colon. The multiple small abscesses are also superficial. In both 
types there is central necrosis and softening, the contents are yellow, 
green or chocolate-colored, contain fat droplets, liver detritus, and the 
amoeba? lie on the abscess walls. In the older cases there is a firm 
connective tissue capsule but round cell infiltration is as infrequent 
as it is in the intestine. Amoebae may be found in the sputum when 
the liver abscess ruptures into the lung, or in the pus of secondary 
empyema. The pathology of complicating myelitis is disputed, but 
the pseudorheumatism and neuritis are probably toxaemic. The diag- 
nosis is easy on careful microscopic examination of the stools. The 
mortality ranges from 1 to 20 per cent.; 7 per cent, of the deaths in 
Cairo are dysenteric. 



III. Indeterminate Dysenteries. 

The classification and cause of these forms are not yet defined; but 
some are apparently primary and others are secondary infections. 
Various microorganisms have been found, such as the colon bacillus, 
proteus, pyocyaneus,pneumococcus, streptococcus, and staphylococcus, 
but their action is still undetermined. Varieties : (a) Catarrhal dysen- 



INDETERMINATE DYSENTERIES 231 

tery, m which the mucous membrane is injected, cloudy, and infiltrated; 
the solitary follicles are swollen and often ulcerated, — the "acute fol- 
licular colitis" seen especially in children; the ulcers are round, deep, 
and small. In some instances there is also inflammation in the small 
intestine. The symptoms are usually mild pain, and muco-bloody 
evacuations, (b) The croupous or diphtheroid dysentery represents 
a severe stage or degree. The epithelium necroses, the submucosa is 
considerably infiltrated, and there are membranous deposits on the 
rugae over slight superficial ulcerations, or there may be deeper, wider 
ulcers with great thickening of all the intestinal layers. This may 
occur (1) as a primary infection, with dysenteric symptoms, marked 
typhoidal symptoms, fever and chill, and frequently has a fatal out- 
come; or (ii) as a secondary incident in various infections; e. g., in 
pneumonia particularly, in typhoid, scarlatina, diphtheria, cholera, 
syphilis, cardiac affections, cachectic conditions, mercurial or other 
poisonings and in uraemia. This secondary form may produce 
marked symptoms or may be clinically latent, (c) The gangrenous 
dysentery is attended by the same changes, but results in enormous 
swelling, softening, and sloughing of dark, gangrenous shreds, meas- 
uring one-quarter to three-quarters inch in thickness, and sometimes 
resulting in tubular sloughs of the larger part of the intestinal cir- 
cumference. Perforation sometimes occurs. In the Cochin China 
endemic form, enlarged glands, splenic tumor and intumescence of 
the liver are found. Coprostasis, foreign bodies and parasites are pro- 
moting factors in all these types. In some cases the Cercomonas, 
Trichocephalus dispar, or Anguillula stercoralis may be found. The 
Distoma haematobium (Bilharz) may cause symptoms closely resem- 
bling those of dysentery; bloody urine, and strangury result from 
invasion of the vesical venous plexus by the Distoma; anatomically, 
hypertrophy of the mucosa, even to the extent of small or large poly- 
poids, may result, as well as superficial ulceration and infiltration of 
the submucosa. 

Treatment of all Forms.— 1. Specific Treatment. — This is limited 
to the bacillary type. Shiga's bactericidal serum seems to have re- 
duced the mortality at least one-half and to have shortened the course; 
in mild cases one and a half to two and a half drams [6 to 10 c.c] 
are injected once; in medium cases two and a half drams [10 c.c] 
twice, and in severe cases one to two ounces [30 to 60 c.c] daily. The 
best results are obtained by early injection. 

2. Prophylaxis. — Drinking water should be boiled, and fruits and 
vegetables should be cooked. In the tropics, sudden variations of 
temperature are to be carefully avoided. 

3. Diet. — Acute and chronic cases must be carefully dieted and the 
patient must be kept in bed. Boiled milk, raw or slightly cooked eggs, 
or the whites of eggs beaten with water should be given to relieve 
colic and tenesmus. The nearest approach to solid food which is 
allowable is well-cooked rice or sago. Broths and cold drinks irritate 
the stomach and excite peristalsis. Some lemonade is permissible. 



232 THE SPECIFIC INFECTONS 

In convalescent acute or in chronic cases, solids should be given late, 
commencing with well-cooked tender meat and starches, and avoid- 
ing vegetables and fruit until convalescence is absolutely established. 

4. Eliminative Treatment. — Sodium or magnesium sulphate are 
given in early cases to cleanse the bowel and to minimize the danger 
of ascent from the lower intestine (5j every two hours until the bowel 
is thoroughly emptied). Aromatic sulphuric acid mxx p. c. is sometimes 
given after the saline treatment. Castor oil is a mild laxative but is 
of little use except in the early stages. Calomel is considered beneficial 
by some writers, by whom it is given in frequent doses and in small 
amounts until slight mercurialization is noted. 

5. Antisepsis. — Beta-naphthol and salol (phenylis salicylas) aa gr. 
x, t. i. d. or q. i. d., are sometimes helpful, although probably but small 
parts of the drugs reach the larger intestine. Bichloride of mercury, 
gr. 3 X o to 20, is efficient in some cases. 

6. Ipecac. — This was introduced from Brazil, by Piso, in 1648. It 
is considered almost specific in India and Brazil, but, like the drugs 
above named, has little effect in the amoebic type. Frayer held that 
it reduced the mortality from 11 per cent, to 5 per cent, in his series. 
In India it is given as follows: food is withheld for four or five hours, 
and then a hypodermic of morphine, or opium by mouth, is admin- 
istered to quiet the stomach and lessen nausea; 15 grains of pow- 
dered ipecac are administered every hour for two, three, or possibly 
four, doses. If the first dose is vomited, the opium and ipecac are given 
again. A mustard plaster should be applied to the epigastrium or a 
turpentine stupe to the abdomen. In Brazil, a decoction is preferred. 
The Pidv. ipecac, et opii and salol may be given aa gr. x for a few doses. 

7. Pain. — Pain necessitates the use of opium, which also decreases 
tenesmus and peristalsis. It is given most efficaciously by rectum in 
a suppository, or, if poorly retained, by enema, mixing Tr. opii deo- 
dorat. tt£ xx with an ounce of starch water. 

8. Local Measures. — Under this caption the use of b ismuth by mouth 
may be mentioned, because its action is for the most part local; doses 
of 3j to ij are necessary, and even two ounces daily are given. Mus- 
grave dislikes the use of bismuth because it cakes in the ulcers. La- 
vage is difficult because of tenesmus and bowel intolerance, and is 
:not without danger, for perforation has resulted from copious irriga- 
tions. The rectal tube must be introduced carefully as the rectum is 
^very sensitive. Tenesmus may be avoided by injection of a cocaine 
or laudanum solution, or a cocaine, opium, or iodoform (five-grain) 
suppository. 

Ac. tannici . . . gr. xv. 

Extr. opii gr. iv. 

Extr. belladonnae gr. j. 

Olei theobromatis * q. s. 

M. et ft. — Suppos. No. iv. 

Carbolic acid and bichloride of mercury solutions are seldom em- 
ployed; Bellei employs as an antiseptic and anaesthetic douche, carbolic 



MALTA FEVER 233 

acid tt£xx, tannin 3j, marshmallow root gij to a quart of warm water. 
Among the other solutions of value are quinine (1 to 1,000 or 5,000, 
Osier), or a weak peroxide solution for the amoebic variety, and 
Thiersch's solution of boric and salicylic acids ; all enemata should be 
warm. Strong silver solutions (1 to 500 or less) cause great pain, 
and weak dilutions are inert; silver, however, is most suitable for 
chronic cases. In the author's experience, Kartulis's method is the 
most valuable; — e.g., J per cent, solution of tannic acid, injecting as 
much as the bowel will tolerate and retain. It kills the amoebae and 
two or three injections are usually sufficient. Kartulis has "never 
been disappointed in hundreds of cases." It may be given in the 
genupectoral position as an enteroclysis, as advocated by Cantani in 
cholera. An irrigator at an elevation of two feet should be used and 
the ordinary rectal syringe should be avoided. 

9. Turpentine Emulsion. — This may be used for tympanites, and 
the ice-bag, or Leiter's coil with opium, may be used for hemorrhage 
or peritonitis. 

10. Colostomy. — In chronic cases, colostomy has been advocated. 



MALTA FEVER. 

Definition. — A specific infection, which is endemic on the coast 
and in the islands of the Mediterranean Sea, is caused by the Micro- 
coccus melitensis , somewhat resembles typhoid, but is character- 
ized by a much longer course, by recurrent, irregular, "undulant" 
fever, severe sweats, splenic tumor, and rheumatoid or neuralgic 
pains. 

History. — Observed about a century ago, it was first described by 
Marston (1858) as a separate disease. Marston, Bruce and Hughes, 
English army surgeons, have been the largest contributors to our 
knowledge of Malta fever. Its distribution is fairly well covered by 
its names, — Mediterranean, Rock or Gibraltar fever, Malta fever, Neo- 
politan or Levant fever. It has also been seen on the Danube, Red 
Sea, Bosphorus; in China, India, the Philippines; in the Canaries, 
Azores, and Antilles; in Venezuela (Caracas fever), Brazil, and South 
Africa. Less than a dozen cases have come to this country. Musser 
and Sailer published an account of the first one. 

Etiology. — The Micrococcus melitensis, which was discovered by 
Bruce (1887), is round or oval, measures 0.3 pt, often occurs in chains, 
is non-motile, and stains with methylene blue, or gentian violet, but 
not by Gram's method. It grows best on 1.5 per cent, beef-water, 
with peptone and agar, in which state cultures grow in the form of 
small pearl-like spots. These after a few weeks become yellowish- 
brown. The bacillus is not found in the blood, but in the urine, even 
after recovery, and in the liver and spleen. The apes inoculated by 
Bruce and Hughes showed a typical clinical course and postmortem 
findings. The disease prevails chiefly between the sixth and thirtieth 



234 THE SPECIFIC INFECTIONS 

years, in the hot, dry weather from May to mid-October, and in old 
and unhygienic buildings. It is not directly contagious. The atrium 
is the lungs (by dust, Hughes), or the alimentary tract (by food or 
drinking-water, Bruce). In Strong's laboratory infection, the con- 
junctiva was the point of entrance. It has been recently suggested 
that mosquitoes and goats convey infection. 

Symptoms. — Symptoms appear after an incubation of six to ten 
days. Some of them so resemble those of typhoid and malaria that 
the three diseases were formerly confounded. The fever rises grad- 
ually, reaching 104° to 105° after a few days. The face is red, there 
are chilly sensations, frontal headache, insomnia, depression, and 
pains in the back and legs. Epistaxis is occasional. The tongue is 
coated, is at first moist, then dry, and fissured, and sometimes bleeds. 
The tonsils are frequently swollen, and the pharynx is red or at times 
ulcerated. Anorexia, nausea, epigastric pain and tenderness, and con- 
stipation, are the rule, and vomiting, icterus, meteorism and diarrhoea, 
with dark, malodorous, mucous, and even bloody stools, are sometimes 
seen. One of the chief anatomical findings is intestinal hyperemia, 
and, in rare cases, swelling or ulceration of Peyer's patches occurs 
(4 per cent.). There is considerable bronchitis and the sputum is 
often streaked with blood. Dyspnoea is quite frequent. The pulse- 
rate is at first between 80 and 90; later it becomes faster, and is fre- 
quently attended by palpitation. Severe sweats occur, usually after 
midnight, and are accompanied by sudamina (febris sudor alls). Ros- 
eola? are never observed. An acute splenic tumor and hepatic intumes- 
cence develop, which are due to degeneration and infiltration by 
round-cells. 

After one to three weeks, the fever, which at first is continuous, 
remits, other symptoms abate, and convalescence is apparently estab- 
lished; but the symptoms again return, and frequently recur severa 
times. The fever curve shows waves accompanying each relapse 
(literally " undulant fever"). The patient becomes weak, emaciated 
and pallid. There is no leukocytosis, the urine does not show the diazo 
reaction, and albuminuria is very uncommon. 

Complications. — Complications, which are uncommon in typhoid, 
are frequent. Pseudorheumatism in one or more joints occurs in 50 
per cent, of the cases (Bruce) and is accompanied by redness, swelling, 
and pain in the shoulders, knees, hips, and sacroiliac joints, and some- 
times also in the bursa?, periosteum and fibrous tissues. Neuralgias 
are common. Orchitis and epididymitis occasionally develop, and are 
usually unilateral and ephemeral. Mastitis is very rare. Occasionally 
polyneuritis develops and is evidenced by partial anaesthesia, hyper- 
esthesia, especially of the soles of the feet, paresthesia and rarely 
paralysis. These result from intoxication and exhaustion. Psych- 
oses and disturbance of the special senses may result from Malta 
fever. 

Skin eruptions occur late in the relapses and are chiefly erythem- 
atous or hemorrhagic, and are sometimes accompanied by hemor- 



MALTA FEVER 235 

rhages from the nose, tongue, gums or lungs; desquamation in scales, 
in large shreds, particularly from the soles of the feet, and falling of 
the hair, are common. Glomerular nephritis, pneumonia, and endo- 
carditis are very unusual. In convalescence, tuberculosis not infre- 
quently develops. 

Course and Prognosis. — In the majority of cases relapses occur 
after two or three weeks. The fever sometimes remains near 104° 
continuously for months. The average duration of the disease is 
ninety days, but Bruce records a case which lasted over two years. 
Hughes describes three types: (a) the undulant, as above described, 
which is the most common type; (b) the malignant, which ends in 
death in from one to three weeks from weak heart, from hyperpyrexia 
(110° Or 111°), or possibly from lobular pneumonia; (c) the inter- 
mittent, which lasts for months. The severity of the infection varies; 
Melland found that 50 per cent, of cases in the Canary Islands lasted 
from two to three weeks, and in only 10 per cent, did the protracted 
undulating type occur. The death-rate is constantly decreasing. In 
the seventh decade of the last century it was over 3 per cent., but it is 
now under 1 per cent. Immunity after one attack is usual, but is not 
absolute. 

Diagnosis. — The diagnosis of Malta fever is often difficult, espe- 
cially the differentiation from typhoid. In Malta fever the roseolse, 
and the bacillsemia are absent; the blood does not respond to the 
Widal test; nor does the urine show the diazo reaction. The course 
of Malta fever is longer than that of typhoid, the sweats are more 
severe, and the joints are inflamed; orchitis, and neuralgias develop. 
A positive diagnosis can be made by the use of Wright's serum reaction. 
The blood responds to this test after the fifth day, and continues to 
do so, in some cases, for three years. Agglutination may be obtained 
equally well with the living or dead cultures; the dilution of the blood 
is 1 to 50, and the time for the test is limited to one hour. The severe 
bronchitis, fever, and sweats may cause confusion with tuberculosis. 
Indeed, the older writers spoke of Malta fever as " Mediterranean 
phthisis." The bronchi in Malta fever are intensely hyperasmic and 
the sputum is frequently blood-tinged. Malaria, ulcerative endocar- 
ditis, febrile pseudoleukemia, and liver abscess, are differentiated 
by the agglutination test. 

Treatment. — There is no specific treatment, though serum therapy 
is likely to prove valuable (Aldridge, Fitzgerald, Ewart). Quinine 
and arsenic are ineffectual. Headache and backache are relieved by 
antipyrin and morphine; insomnia by bromides, chloral and hyo- 
scine; diarrhoea by tr. ferri chlor. ; pseudorheumatism by heat, by 
wool investment, by tr. iodi, locally, and by salicylates, internally; 
orchitis, by local heat and by suspensory elevation. The general 
therapy is the same as it is in typhoid. Milk diet lessens the chance 
of intestinal complications, though Dalton advocates a solid diet. In 
convalescence a change of climate is necessary. 



236 THE SPECIFIC INFECTIONS 



BERIBERI. 

Definition. — Beriberi, or polyneuritis endemica (Baelz, Scheube), is 
an endemic and epidemic affection of the tropics and subtropics, of 
unknown etiology, characterized anatomically by degenerative inflam- 
mation of the peripheral nerves, and clinically by motor and sensory 
disturbances, anasarca, cardiac disturbance and by a subacute or 
chronic course. Beri is said to signify a sheep's gait, and kakke also 
means disturbance of the gait. 

History. — Beriberi is mentioned in the oldest Chinese writings and 
was observed in the Roman legions, 24 B. C, by Strabo and Cassius. 
In the seventeenth century, beriberi was noted in Brazil and in the 
Malay archipelago; in recent times (1835) it has been described by 
Malcolmson in India; by Baelz, Scheube, Grimm, and Miura in 
Japan; by the physicians in the Dutch Oriental colonies; and by 
Birge, Putnam, and Bonduret in this country. 

Distribution. — The main foci of beriberi are (1) the Malay archi- 
pelago, Sumatra, Borneo, and Java; also China, India (where it is 
decreasing), the Philippines, Japan, and even Australia. The mor- 
tality has been very high among the Chinese coolies in the Dutch 
possessions, where epidemics developed from endemics. (2) Africa, 
including the mainland and the islands. (3) America and the West 
Indies, Brazil, Honduras, and Cuba. Cases have appeared in Dublin 
(1894-1898, with forty-two deaths), in England, and in Paris. Scheube 
doubts that the cases which developed in the United States, in the epi- 
demic at Tuscaloosa, Alabama, were beriberi, but from description, 
they are apparently identical with oriental beriberi. 

Etiology. — The etiology is greatly disputed and there are two dis- 
tinct views: (1) that it is an acute infection (Baelz, Scheube), because 
it occurs in the young (fifteen to thirty-five years) and healthy, it 
occurs in certain localities as epidemics and endemics, it occurs in the 
summer months, and in moist, alluvial land near the sea, and near 
the river mouths, — i. e., the same telluric conditions promote beriberi, 
which promote malaria. It is considered by some persons to be con- 
tagious, though no constant microorganism has been found. The 
fact that many cases develop in houses, barracks, and ships is an argu- 
ment in favor of the theory of contagion. In the 80,000 cases which 
developed among the Japanese troops in the Russo-Japanese War, 
Kokubo frequently found a coccus. (2) The second view is that beri- 
beri results from food. Shelled rice is said to have caused it in the 
Dutch East Indies, and raw fish is considered the cause of the disease 
among the Japanese (Miura). The use of fish in the navy was for- 
bidden by Takaki, and the mortality fell from 25 per cent, to almost 
nothing. Natives are more often affected than Europeans, and males 
more frequently than females. Improper diet may be a cause of 
beriberi or at least an indirect factor. In 1879 there were 8,197 cases 
in Japan and in 1891 this number decreased to one. Poor food, 



BERIBERI 237 

overcrowding and lack of hygiene are important and avoidable 
factors. 

Symptoms. — The incubation is long, probably several months, and 
the development of the disease is due to repeated infections. The 
symptoms are threefold: (a) those of multiple neuritis; (b) dropsy, 
and (c) cardiac insufficiency. 

(A). Neuritic Symptoms. — A more detailed description of these 
symptoms will be given under Multiple Neuritis. Anatomically 
there is the same symmetrical degeneration (or inflammation) in the 
distal parts of the peripheral nerves to which, however, it is not 
limited; the phrenic and pneumogastric nerves and the cardiac, renal, 
and solar plexuses, are often involved; the nuclei of the sheath 
multiply; the axis cylinders degenerate; there is a lumpy de- 
generation in the medullary sheath; and later, there is connective- 
tissue hypertrophy. In eight cases there were degenerative changes 
in the cord, anterior horns, and posterior ganglia. . Clinically, the 
neuritis comes on gradually and runs a chronic course, which is 
varied by acute exacerbations. 

1. Motor Symptoms. — The muscles of the calves of the legs, the 
knee extensors, and the abductors and flexors of the thigh are weak- 
ened, flaccid, swollen and are frequently atrophied. The muscles are 
more frequently tender than the nerve-trunks. In severe cases the 
trunk, arms and, rather frequently, the face, are involved. The muscles 
are anatomically much degenerated. Phrenic weakness and vagus 
symptoms, such as rapid heart, vomiting, epigastric oppression, or 
digestive disorder are not infrequent; the lungs are sometimes acutely 
emphysematous, which results from involvement of the pulmonary 
plexus. Symptoms of involvement of the larynx, of glossopharyngeal, 
hypoglossal or ocular participation are more rare. Cramps in the 
calves of the legs and fibrillary contractions are frequent, but ataxia 
is rather uncommon, although the name beriberi refers specifically to 
disturbed locomotion. The gait is described as like that of one walk- 
ing in wet clothes or wading in water. Tremors are rare. 

2. Sensory Symptoms. — Paresthesia is common. Hypsesthesia is 
most marked in the distal parts, though the sole of the foot is exempt; 
it is more frequent than anaesthesia, which is rarely complete. Hyper- 
esthesia is not very frequent, but may occur over the spine and ab- 
domen. Pains over the joints and intercostal spaces are quite common. 

3. Trophic Symptoms. — These are uncommon. They include joint 
relaxation, herpes or skin atrophy. 

4. Reflexes. — The skin reflexes are seldom abolished. Reduc- 
tion of the tendon reflexes develops equally with the paralysis. 

5. Degeneration. — Slight reaction of degeneration is common and 
may be marked in severe cases. It occurs particularly in the leg. 

(B). Dropsy. — Dropsy to some degree occurs in 97 per cent, of cases; 
it may be marked in the legs, and face, and in all the serous cham- 
bers. It is most severe in the pericardium, is quite severe in the 
pleura?, and is least severe in the peritoneum. It is caused by cardiac 



238 THE SPECIFIC IXFECTIOXS 

and perhaps also by vasomotor involvement. Dropsy invariably 
occurs in fatal cases. 

(C). Cardiac Insufficiency. — This occurs particularly in the acute 
cases; death may result in a day, and acute forms in 65 per cent, of 
the cases lead to a protracted and distressing death within two weeks. 
There is palpitation, cardiac or epigastric oppression, or actual pain; 
tachycardia, dyspnoea, and cyanosis develop; the right ventricle is 
dilatated, the first apical tone is weak; there is splitting of the heart 
tones, gallop-rhythm, and systolic or even diastolic functional bruits; 
the urine is decreased in amount, in phosphates, and in uric acid; 
the liver is turgid. Anaemia is marked and the leukocytes may be in- 
creased. The heart failure may be accompanied by vocal cord par- 
alysis and weakness of the respiratory muscles. Acute pulmonary 
oedema is usually fatal. The heart muscle is pale, friable, colloid, 
or is the seat of acute myocarditis. 

The types of beriberi only accentuate some of the above-named 
symptoms, any one of which may stand out prominently. (1) The 
rudimentary form may begin with slight fever, and with catarrh of 
the nose, air-passages, and alimentary tract. There is a slight oedema 
of the ankles; muscular weakness, which occurs especially in the 
legs, indicates neuritis; muscular tenderness, paresthesia, hypaesthe- 
sia, and palpitation are also symptoms. (2) The atrophic form is 
marked by atrophy and paralysis. If oedema does not develop, both 
of these types may be called the "dry forms." (3) The dropsical 
form is characterized by much transudation and by pronounced insuffi- 
ciency of the heart. (4) The acute cardiac or pernicious form (v.s.). 

Diagnosis. — Diagnosis of beriberi is difficult when it occurs in the 
temperate countries. The leading points are (a) the multiple neuritis, 
which is most marked in the legs; (b) vagus neuritis and cardiac 
insufficiency; and (c) dropsy. 

Prognosis. — The death-rate varies, even in the same endemic 
locality. In Japan and the Dutch Indies it ranges between 3 and 4 
per cent. ; in Brazil it formerly varied from 50 to 75 per cent. ; and in 
the Malay archipelago it reached 40 to 50 per cent. Death results 
primarily from heart failure, secondarily from paralysis of respiration, 
less frequently from uraemia, embolism of the lungs, aspiration pneu- 
monia, intercurrent disease, or marasmus. Even in recovery, perma- 
nent residua are common, such as weakness, obstinate contractures 
of the legs (necessitating tenotomy), absence of knee-jerk, and cardiac 
instability and hypertrophy. Recurrences during ten, twenty, and even 
thirty years, are common. 

Treatment. — In the early stages of the disease purgation and salicy- 
lates are beneficial. In the later stages, electrotherapy and other 
measures which are employed in multiple neuritis (q.v.) are indicated, 
and the heart should receive stimulation. Venesection is advisable 
in order to relieve the overladen right heart and the dyspnoea, and 
promote action of the kidneys. Digitalis is strongly recommended by 
some, whereas others fail to find anv benefit from its administration 



ANTHRAX 239 

and attribute such a result to degeneration of the vagus. In dropsical 
forms it is helpful as is caffeine. Blisters and the ice-bag over the 
heart, bromides and belladonna, may mitigate cardiac unrest and 
palpitation. (See Treatment of Valvular Disease of the Heart.) 

ANTHRAX. 

Anthrax is one of the zoonoses — (diseases acquired from animals). 
Glanders, foot-and-mouth disease, vaccinia and hydrophobia consti- 
tute the remainder of this group. Actinomycosis is less a zoonosis 
than a disease acquired from a common cause by man and beast. 
Anthrax is also called splenic fever, pustula maligna, and carbunculus 
contagiosus. 

Definition. — It is an acute infection caused by the Bacillus anthracis, 
and is usually communicated to man from the herbivora. 

History. — Over a century ago Morand and Fournier distinguished 
between the simple carbuncle and that of anthrax, which could be 
inoculated. The bacilli were seen by Pollanders (1855) and Branell 
(1858), but Davaine (1864-1873) worked out all the essentials of the 
disease and noted that the organisms were bacteria. It remained 
for Koch with his epoch-breaking technique to find the spores and 
to absolutely differentiate the disease, which is now one of the best 
known maladies. 

Bacteriology. — The anthrax bacillus is the largest pathogenic mi- 
crobe, and measures 3 to 10 by 1 to 1.5 /*. In growths it may occur 
singly or in chains of 2 to 10 bacilli. The ends are slightly rounded, 
and the chains somewhat resemble the phalanges of the finger for 
the organisms lie end to end. They are non-motile, and transparent, 
and may be stained by Gram's method, and also with various dyes, 
especially with Bismarck brown. At high temperatures they grow in 
long, thread-like, winding, segmented filaments. Spores are absent 
in the cadaver or in the living tissue, possibly because of the presence 
of carbonic acid; in the living tissues they multiply by fission. 

In attenuated cultures, one spore develops for each bacillus; these 
become bacilli, which, when young, may be slightly motile, and are 
extremely resistant to drying and to high temperature. 

Cultures. — The bacillus is an obligate aerobe which requires oxygen 
and carbon dioxide, and grows best on neutral or weakly alkaline 
media and at a temperature between 95° and 102°. Stab cultures of 
agar are characteristic. A white, milky yet transparent and band-like 
growth appears in one or two days, which develops horizontally in 
blood serum, and grows downward at an acute angle, so that in three 
days it resembles a quill with a feathered upper end. Growths on gel- 
atin appear to have a thick, wooly covering. The gelatin liquefies after 
a few days, and a white, granular sediment falls to the bottom of the 
tube. The bacillus loses its virulence in blood which has been rapidly 
dried, but in blood which has been slowly dried, it develops spores. 



240 THE SPECIFIC INFECTIONS 

Anthrax is endemic and epidemic in Europe and Asia. There 
are persistent foci in Germany, especially in Saxony, parts of 
Bavaria, and in Frankfort; in France, in the provinces of Burgundy, 
and Auvergne; in Hungary; in Russia, principally in Siberia (the 
"Siberian plague"); in China, India, and in South America. 
Anthrax is rare in America, though small epidemics have appeared 
in Delaware and in Pennsylvania. Among animals, the herbivora 
are most often affected, especially sheep and cattle, and in 
Russia, horses. Omnivora are more susceptible than carnivora. 
Mice, guinea-pigs, rabbits, dogs, and fowls, rarely acquire the disease. 
Pasteur thought that earth-worms carried the bacilli from buried 
bodies to the surface. Transmission of the spores by means of snails, 
flies and fleas is possible. Spores reaching water may be widely 
disseminated. The germ may have a facultative saprophytic exist- 
ence on vegetable media. 

Infection may be carried to man from animals, and, on rare occa- 
sions, from other human beings. Of Koranyi's cases, 65 per cent, 
were attributed to sheep and 35 per cent, to cattle; Bourgois considers 
that the greatest percentage comes from cattle, the second largest 
from sheep, and the third largest from horses. 



I. External Anthrax. 

External anthrax is by far the most common type. The atrium 
is through an abrasion of the skin, and possibly through intact 
hair-follicles. Koch observed that sheep were infected by fly-bites 
on the exposed skin of the neck. Shepherds, coachmen, and all 
those who may attend diseased animals; butchers, tanners, wool- 
sorters and persons who may handle diseased hides or meat; and 
saddlers, tanners, rag-pickers and gardeners are most likely to acquire 
the disease. The bacillus may enter the system through insect-bites, 
and bruises. Jacobi records infection from a hypodermic needle 
which was first used on a patient suffering from anthrax. The spores 
are more virulent than the bacilli. 

Site of the Pustula Maligna. — In Koch's collection of 1,077 cases, 
the exact distribution is noted in 966; 51 per cent, developed on the 
head and face, 38 per cent, on the upper extremities, 2 per cent, on 
the lower, 5 per cent, on the neck, and 4 per cent, on the trunk. That 
is, the exposed parts are the usual seat of primary infection. The 
lesion is usually single, but several pustules or carbuncles may develop, 
possibly from inoculation by the finger-nails in scratching. 

Symptoms. — The incubation lasts two or three days. A small red 
prominence is first seen, which resembles an insect-bite. It itches, and 
burns, and in about twelve hours develops a small vesicle. This is 
filled with yellowish or blood-stained serum, which is purulent if rup- 
tured or scratched, and which dries with scab formation. It develops 
a dark, dry, central, necrotic, leathery slough, which is caused by 



EXTERNAL ANTHRAX 241 

streptococcic infection, and is surrounded by dense round-cell, fibrin- 
ous, and often hemorrhagic, infiltration. This in turn is surrounded 
by oedema of the connective tissue, in the deeper lymphvessels of 
which the Bacillus anthracis abounds. If the carbuncle becomes 
extended, a circle of new vesicles, or even two or three concentric 
circles of vesicles appear, which fuse and increase the infiltration and 
oedema. The eyes may be closed by swelling of the lids, or the lips 
may be so swollen that the jaws cannot be opened. Demarcation 
may now occur, followed by sloughing; granulation tissue and cica- 
trization or general injection develop, and the adjacent lymphvessels 
and glands become infected, soft, and hemorrhagic. This usually 
occurs on the fourth to the sixth day, or earlier in cases of violent 
infection or of reduced physiological resistance. It is marked by de- 
pression, by headache, backache, pain in the limbs, chilliness, con- 
tinuous or remittent fever, soft pulse, rapid breathing, vomiting of 
mucus or blood, vertigo, leukocytosis (20,000 to 70,000), colic, diar- 
rhoea, and collapse. Hemorrhages may occur or even gangrene may 
develop around the carbuncle. Anthrax bacillsemia is sometimes 
found. The mind is usually clear, although delirium, convulsions or 
coma may develop, and death may occur on the seventh to ninth day 
with an antemortem fall of temperature. Toxaemia and septicaemia 
cause the symptoms given above. In fatal cases there is only slight 
rigor mortis but rapid decomposition, dark fluid blood, hemorrhages 
into various tissues, swelling of the lymph glands, and lymphadenoid 
tissue of the intestine and sometimes of the spleen. In the liver, 
kidneys, brain and meninges, deposition of bacilli, and hemorrhages 
and swelling may be found; the bacilli are seen less in the 
large vessels than in the capillaries of the brain, kidneys, lungs, 
spleen and heart. Bourgois describes another cutaneous form 
of the disease in which there is great oedema {charbon blanc, anthrax 
oedema), but no pustule or carbuncle. He considers that it occurs 
more often on the trunk of the body than does the carbuncle. 

Diagnosis. — In most cases this is not difficult. The simple car- 
buncle resembles that of anthrax, in that it is also hard, has a prom- 
inent central necrosis, is surrounded by oedema, and sometimes is 
vesiculated. It usually causes great pain, has numerous openings 
which discharge ordinary pus, and is often malodorous. The anthrax 
carbuncle, however, may be differentiated by the presence of bacilli, 
by depression of the necrotic centre, by the corona of vesicles, by 
more rapid evolution, by greater oedema, and by lack of odor. Glan- 
ders may be distinguished by involvement of the mucosa?, by painful 
nodes without eschars, and by ulcerations which discharge the Bacil- 
lus mallei. It is often difficult to recognize Bourgois's charbon blanc. 

Prognosis. — The prognosis is more favorable in children than in 
adults, in cases with local than in those with general symptoms, and 
in those with simple carbuncle than in those with oedema. In Koch's 
collection of cases, 68 per cent, recovered. Nasarow's figures show 
26 per cent, mortality when anthrax occurs in the head and face, 23 

16 



242 THE SPECIFIC INFECTIONS 

per cent, when it occurs in the trunk, 19 per cent, in cases of infection 
in the neck, 14 per cent, in the upper, and 5 per cent, in lower ex- 
tremity localization. 

Treatment. — Prophylaxis. — Infected animals should be cremated 
entire and their hides and wool should be destroyed. Toussaint 
(1880) and later, Pasteur, Chauveau and Colbert, attenuated the viru- 
lence of anthrax cultures by exposing them to sunlight or to increased 
atmospheric pressure, and used them to immunize animals. In France 
(1882-1893), 1,788,677 sheep were thus inoculated, with a resulting 
mortality of 0.9 per cent, and 200,962 cattle were also inoculated, 
and a 0.3-per-cent. mortality occurred. 

Active Treatment. — Wounds in those who have been exposed to 
infection should be promptly washed with strong sublimate solution. 
Cauterization with the live cautery, with carbolic or nitric acids, caus- 
tic potash; surgical excision through sound tissue; injections of iodine 
or corrosive sublimate; these have all been recommended, but it is 
also maintained that equally good results may be obtained by eleva- 
tion, by the use of mercurial paste, and by expectant treatment, 
which at least avoid dissemination of the parasite through sound 
tissues. Erysipelas serum has apparently been useful in anthrax in- 
fections. Sclavo (1903) reported 164 cases which were treated by 
serotherapy; the mortality was but 6 per cent. In 1,073 cases treated 
with Mendez's serum, the mortality was but 4 per cent. 



II. Internal Anthrax. 

Internal anthrax is less frequent than the external type. It occurs 
in the alimentary and respiratory tracts. 

1. The alimentary form (mycosis intestinalis), was first described 
by Wahl and Recklinghausen, and was more fully discussed by Wal- 
deyer and Munch. Bacilli may enter the system through cuts in the 
mouth and throat, but usuallv directlv invade the intestines and stom- 
ach, which are more frequently infected by spores in milk or water 
than by diseased meat. The gastric juice kills the bacilli but not 
the spores. Peasants often eat the pickled meat of diseased animals 
without being infected. In Wurzen, Saxony, there were 206 cases of 
intestinal anthrax in 1877. 

Symptoms. — There may be prodromal chills, fever, epigastric or 
lumbar pains, or depression. The onset is, however, usually abrupt, 
with fever, coated tongue, thirst, and vomiting of mucus or of blood. 
This is followed by sensitiveness or great pain over the bowels, by 
serous and afterward by bloody movements, meteorism, dyspnoea, 
weak pulse, and by symptoms of collapse which resemble those 
seen in the generalization of infection in the cutaneous form. 
Secondary carbuncles, or more often hemorrhages into the skin of 
the neck and of the abdomen, may develop. The course is usually 
severe and, in some instances, is peracute; death may result in 



INTERNAL ANTHRAX 243 

two or three days, in well marked cases, although recovery is possible. 

Diagnosis. — The history of the case, the finding of bacilli in the 
stools and in the blood, or the findings at autopsy, determine the diag- 
nosis. In the small intestine there are changes like those of the cuta- 
neous carbuncle. These consist of localized induration with central 
sloughing which usually occurs opposite the mesenteric attachment 
and is accompanied by surrounding hemorrhage and oedema in the 
mucosa, and of swelling of the solitary follicles, of Peyer's patches, 
of the mesenteric glands, and of the omental and retroperitoneal cel- 
lular tissue. The bacillus is found in these lymphadenoid structures 
in large numbers and sometimes also in the chylevessels and portal 
bloodvessels t The greatest changes most frequently occur in the 
upper small intestine, sometimes in the stomach or ileum, seldom in 
the colon, and most rarely m the rectum. More than thirty or forty 
foci may be seen in the small gut, but the lesions in the stomach 
or rectum are fewer in number and more discrete. Secondary em- 
bolism of the intestinal arteries may result from anthrax of the skin, 
in which event hemorrhagic stools are uncommon. Serohemorrhagic 
fluid may be found in the peritoneal cavity. Treatment is without 
effect, though ipecac, calomel and bichloride of mercury are often 
recommended. 

2. The respiratory form was described by Bell (1840), and by 
Spear and Carpenter (1881) in England, as the "wool-sorters' disease"; 
and by Eppinger (1894) in Steiermark, Austria, as the "rag-sorters' 
disease." Infection may, on rare occasions, occur in the nose, larynx, 
tonsils (Wiggin), or bronchi. Particles of inhaled chalk are thought 
to facilitate infection by producing minute traumata, but the bacilli 
are apparently capable of entering the uninjured bronchioles and 
alveoli. Wool-sorters' disease results especially from infection by 
hides imported from Russia and Brazil, and, in 1897, anthrax developed 
in this country from hides of Chinese origin. 

Symptoms. — Prodromes are uncommon. The symptoms begin sud- 
denly with chill and high fever, tachypncea, and dyspnoea; there are 
bronchitic and irregular pneumonic findings; and the sputum, which 
contains in some instances the pathognomonic bacilli is viscid or 
hemorrhagic. The later symptoms are cyanosis, which is caused by 
diffuse mediastinal infiltration; serous pleurisy, weak heart, and the 
terminal collapse and antemortem fall of temperature. Icterus, hsema- 
turia, glycosuria, and anthrax endocarditis have been observed. The 
sensorium is clear to the end in most of the fatal cases, though con- 
vulsions and coma, which in some cases are due to meningeal hemor- 
rhage, may occur. The patient may die as early as the second or 
third day. The mortality in rag-sorters' disease is 50 to 87 per cent., 
and is rather lower in wool-sorters' disease. At the autopsy the special 
findings are as follows: the bacilli enter the ultimate air-tubes and 
alveoli, wherein they may produce alveolar desquamation and cellulo- 
fibrinous exudation — the analogue of the carbuncle — and much sero- 
hemorrhagic exudate. The latter is comparable to the skin oedema. 



244 THE SPECIFIC INFECTIONS 

In cases where there is much cellular exudate the bacilli become 
decreased, and recovery may result from demarcation; where there 
is much serous infiltration the bacilli are abundant, and extension of 
the infection is likely along the lymphvessels in the direction of the 
mediastinal cellular tissue, of the peribronchial lymph glands and of 
the pleural, which may hold as much as four quarts of anthrax-infected 
serous blood-stained exudate. 

Treatment. — The disease may, to a great extent, be prevented by 
sterilization of the germ-laden hair, of hides, or of hair used in the 
manufacture of paper. The actual therapy is wholly symptomatic 
and supportive. 

3. Anthrax septicaemia is a rare form in which the blood is charged 
with bacilli, though no point of entrance can be found. It is almost 
always fatal. 

GLANDERS. 

Definition. — An acute or more often a chronic contagion, which is 
caused by the Bacillus mallei. It is characterized by the formation of 
nodules and ulcers, which occur chiefly in the nose and skin, and less 
often in other structures. It is observed largely in the horse, which 
is the main source of human infection. 

Etiology. — Glanders and farcy were known to Aristotle and Hip- 
pocrates. The Bacillus mallei was discovered by Loeffler and Schuetz 
(1882), and independently by Bouchard, Capitau, and Charrin. By 
its discovery, glanders and farcy were identified as one disease. Weich- 
selbaum (1885) first found the bacillus in human infection. It closely 
resembles the tubercle bacillus morphologically, but is shorter and 
thicker, and measures 2 to 5 by 0.4 to 1.5 /jl; it is straight or slightly 
bent; its ends are somewhat rounded; it is usually single, but may 
lie in pairs or groups; and it has no movement. It stains with the 
alkaline anilines, easily in cultures but with more difficulty in sections, 
and the bacillus tinges unevenly, showing lighter areas, which are 
thought by some to be spores. It is a facultative aerobe and its most 
characteristic culture is that grown on the potato, in which a thin 
light yellow film . develops in two days, soon becomes amber- 
colored, and in eight days assumes a weakly red tinge with somewhat 
greenish-blue borders. The atrium is usually the skin, through 
which the bacillus enters by some small, perhaps microscopic, 
lesion. Babes considers that infection may take place through the 
intact mucosa of the nose and air-passages. Horse-bites may cause 
inoculation. Infection may also occur through the conjunctiva, the 
nose, the respiratory tract, or very rarely, the digestive tract (Nocard). 
Man is usually infected by chronically diseased horses; man-to-man 
infection is far less frequent. The bacillus is found in the nasal 
nodes (glanders) ; in the skin nodes (farcy) ; in the lymphvessels and 
glands (in which its virulence is greatest) ; in the saliva, urine, sweat, 
semen and in the blood-current, where it occurs more frequently in 



GLANDERS 245 

man than it does in animals, for in the latter it is found in the most 
acute cases only. 

The vitality of the bacillus is not great. It is soon destroyed in pus, 
but may endure for three or four weeks in the viscera of cadavers or 
three or four months in cultures; it is rapidly killed by sunlight, but 
persists two or more weeks in damp protected places. It is killed in 
two minutes at 212°, in fifteen minutes by 1 to 1,000 sublimate solution, 
and in one hour by 5 per cent, carbolic solution. Babes (1890) and 
Kalming (1891) isolated a toxin, and Kalming, during his re- 
searches, succumbed to acute glanders. Hellmann (1891) isolated 
mallein, and Babes (1892) morvine, both of which are successfully 
injected for diagnosis and for immunization. The horse, ass, and 
mule are the most susceptible animals, and from them, goats, sheep, 
cats, lions, rabbits and guinea-pigs may be inoculated. Babes found 
that in some localities half the horses have latent glanders. Cattle, 
mice, rats, and fowls are practically immune. Infection is carried by 
the nasal or cutaneous discharge, whence glanders and farcy are chiefly 
observed in stable-boys, coachmen, farmers and veterinary surgeons. 

Symptoms, Pathology and Course. — These are considered under 
two topics: (A). Farcy, the cutaneous type; (1) acute or (2) chronic; 
and (B). glanders, the nasal type, (1) acute or (2) chronic. In most 
cases the types are not wholly distinct, though symptoms of one local- 
ization may prevail. 

( A) . Farcy. — 1 . Acute Form. — The incubation is from three to five 
days, rarely two to three weeks, and is attended by depression, anorexia, 
nausea, headache, and leg pains. The infected point on the skin 
shows infiltration, which may heal only to break out anew. Lymph- 
angitis and lymphadenitis are present, but are less marked than in 
the horse, and result in lymphangitic farcy-buds. Subcutaneous and 
cutaneous nodes or areas of diffuse infiltration develop. These swel- 
lings are classed with the infective granulomata, are composed of 
epithelioid, lymphoid, and white blood cells, and contain the bacilli, 
which are free, rarely intracellular, and most abundant in the centre 
of the node. Early sections are succulent and show central necrosis, 
which is followed by suppuration and ulceration. The ulcers are pain- 
ful, deep, and crater-like, with sharply cut, everted borders, and with 
speckled bases; they have a thin, puriform, hemorrhagic, or ichorous 
discharge, and they often fuse. Throm bo-phlebitis, diffuse phlegmons, 
or gangrene may develop. The rise of the fever may closely resemble 
the ladder-like ascent of the temperature in typhoid. Chills are com- 
mon. Polyarthritis and large muscular abscesses are frequent. In 
some cases a skin eruption occurs which is successively macular, papu- 
lar, and pustular, and resembles that of smallpox except that it is 
rarely umbilicated; it may be scant and scattered, or very diffuse, 
and even confluent; and may affect the face, extremities, mouth, 
throat, and conjunctivae. The patient is often delirious, and has an 
offensive diarrhoea; the pulse becomes rapid, and fresh skin nodes 
develop, which are accompanied by ulceration or perhaps gangrene. 



246 THE SPECIFIC INFECTIONS 

The pulse is fast, small, and irregular; the urine contains albumin, 
or casts, or shows the diazo reaction, and death occurs in about two 
weeks from exhaustion or from lung inflammation. In the horse, acute 
farcy occurs with acute nasal localization. 

2. Chronic Form. — Chronic farcy shows the same skin changes, 
but they are very gradual in onset, slow in progression, are unaccom- 
panied by essential inflammatory reaction or by lymphatic invasion. 
For the first month or two there are pains in the limbs and joints, and 
after a few weeks, indolent swellings in the extremities and in the peri- 
articular tissues appear. These are followed by ulceration. The 
ulcers may cicatrize, but break out again after several months, and 
therefore somewhat resemble lupus, which heals on one side and de- 
velops on another. Muscular abscesses may appear, and are very 
often located in the pectoralis, biceps, brachialis, and gastrocnemius. 
The course lasts for months or years (two to eleven). Recovery occurs 
in 50 per cent, of the cases (Bollinger), or death results from exhaus- 
tion and acute dissemination. In horses the lymphvessels and glands 
are greatly swollen, and appear as sausage-shaped masses, on account 
of which fact the term " farcy" was used by Vegetius. In horses the 
skin eruptons and orchitis are more frequent than in man. 

(B). Glanders. — 1. Acute Nasal Form. — The conjunctiva? are 
sometimes swollen, but the process generally begins in the nose after 
an incubation of three or four days. Miliary nodules develop. These 
are elevated, are yellowish-white in the centre, grow to the size of a 
pea, are surrounded by a pale red zone, and become ulcerated. New 
nodes form on the edges of the ulcers, which break down, fuse with 
them, and discharge a thin, puriform, dirty, sanguinolent fluid. Diph- 
theroid deposits or crusts form; desiccation may also occur. Ulcera- 
tion may erode the bone or cartilage, and cause perforation of the 
septum. The nose is swollen and eroded externally, and the lesions 
may resemble those of erysipelas. The process reaches the mouth by 
the lymph channels or by thrombophlebitis. Perforation of the palate 
may occur; the tongue, gums, or tonsils are invaded; the angular 
lymphatic, parotid and submaxillary glands are swollen, and the larynx, 
and finally the lungs, are infected. Beregin found that microscopic 
nodes may develop in nearly all the parenchymatous organs, the liver, 
kidney, spleen, and brain. In the lungs the nodes may resemble 
miliary tubercles, or actual hepatization (pneumonia malleosa) may 
develop, and is frequently accompanied by hemorrhage, abscess form- 
ation, gangrene, a distressing cough, and raspberry, mucopurulent, or 
sometimes stinking sputum. Secondary suppuration in the bones, 
muscles, joints or skin, may develop. The course is that of acute 
farcy, though perhaps more rapid, and is attended by drenching 
sweats, diarrhoea, clouded sensorium, and convulsions; and death 
occurs in one or two weeks. The blood is thin and the leukocytes are 
increased. 

2. Chronic Nasal Form. — This is similar to acute glanders except 
that it is chronic. It is less frequent, and in forms which are limited 



TETANUS 247 

to the nose, confusion with other diseases is frequent. When nasal 
involvement is slight it may clinically and pathologically resemble 
pulmonary tuberculosis, chronic coryza, pyaemia, or osteomyelitis. 
Recovery is infrequent, though healing by cicatrization may result. 
According to Babes, recovery may take place or, at least, the malady 
may "slumber," possibly to be aroused later by trauma or some 
other infection, notably symbiosis with the staphylococci. Death 
occurs from exhaustion or from generalization by the lymphangitis 
or thrombophlebitis. 

Diagnosis of Glanders and Farcy. — Typhoid, pyaemia, rheumatism, 
erysipelas, variola, syphilis, lupus, tuberculosis, and anthrax may cause 
confusion, but the surroundings, the history and the bacteriology of 
the case determine the diagnosis. The cultural findings are proven 
by intraperitoneal inoculation of a guinea-pig, in which orchitis should 
develop rapidly. Injections of mallein differentiate the disease in 90 
to 95 per cent, of the cases for they produce a rise of temperature of 
three degrees or more. The bacilli are agglutinated by the serum of 
normal horses in a dilution of 1 to 200, and of those subject to glanders 
in a dilution of 1 to 1,000. 

Treatment. — The prophylaxis of glanders is like that of anthrax. 
The principal measures indicated are isolation of diseased, and crema- 
tion of dead, animals, and the use of strong antiseptics in wounds in 
persons exposed to infection. Skin ulcers should be curetted and 
bandaged antiseptically; if they are obstinate, the live cautery should 
be applied. Infection of the nose should be treated by carbolic douches, 
zinc chloride paste, iodol, or iodoform. Arsenic, mercurial inunctions, 
iodides, and quinine and alcohol for the maintenance of strength are 
recommended. Injections of mallein may prove of therapeutic as 
well as of diagnostic value (Babes, Pilavios). Large doses of potas- 
sium iodide have been recently recommended. 



TETANUS. 

Definition. — Tetanus, or lock-jaw, is an acute infection caused by 
the tetanus bacillus and is characterized clinically by greatly increased 
reflexes, by muscular rigidity, and by tonic spasms, such as trismus, 
and opisthotonos. Tetanus is literally tension or stretching. The dis- 
ease is described in Hippocrates' aphorisms. 

Etiology.— In 1884, Carle, Rosenbach, and Rattone produced the 
disease by inoculations of pus, and in the same year, Nicholaier dis- 
covered the tetanus bacillus, of which Kitasato (1889) first obtained 
pure cultures from wounds and from earth, and found it an obligate 
anaerobe. The Bacillus tetani measures 3 to 5 by J to h a, and is en- 
larged at one end, in which there is a spore, thus having a pin-head 
or drum-stick shape. It becomes thread-like in cultures. It stains 
readily by Gram's method, and is delicately flagellated and therefore 
motile. It is anaerobic and cultures emit a smell like that of an 



248 THE SPECIFIC INFECTIONS 

onion. It is very difficult to isolate but grows well in sugar solutions. 
The bacillus is very enduring, and lives long, even if dried or 
frozen; the spores may live eight years. It always exists in the 
primary wound and is thought to exist only on rare occasions in 
the tissues of the brain and cord, but recent figures show that 
it is present in 44 per cent, of the severest infections, so that 
tetanus no longer seems to be a simple toxaemia. The bacillus 
has been found in the blood and sputum. Tetanus is usually 
classified as traumatic or idiopathic (rheumatic); the so-called 
idiopathic form is similar to idiopathic erysipelas, for the atrium 
is either unseen, is microscopic, or is apparently through the pharynx. 
The bacillus produces toxins which are 100 to 400 times as toxic 
as strychnine and which in turn produce the symptoms. Brieger 
and Cohn speak of tetanin, tetanotoxin, and spasmotoxin; Ehrlich 
and Babes of tetanus spasmin and lysin, and Faber of a toxin which 
resembles the diastases. The bacillus does not produce inflammation, 
though mixed infections are usual. Tetanus symptoms result from 
the tetanus toxin alone, but both infection and virulence are enhanced 
by association with various putrefactive microorganisms, and innocu- 
ous solutions of tetanus poison become lethal if combined with steril- 
ized cultures of these putrefactive bacteria. Mice, guinea-pigs and 
rabbits, are inoculable. In nature the bacillus is found in the alimen- 
tary tract of herbivora, whence it also occurs in manure, in garden 
earth, in street or house dust,. in hay, in putrefying fluids, and in splin- 
ters. Though it is spread over the world, the disease is ten to twenty 
times as frequent in the tropics as it is in temperate zones, because 
the bacillus thrives in heat. More cases exist in Prague than in Ber- 
lin. It may lurk in certain districts, as it did formerly in the Eastern 
end of Long Island, or as it does in the West Indies where negroes are 
more often and more seriously affected than whites. 

Mode of Infection. — Incised wounds are obviously less dangerous 
than punctured, gunshot, or contused wounds or hsematomata. Tet- 
anus occurred less frequently in our Civil War than it did in the 
Spanish-American conflict, in which many cases developed among the 
Spaniards. It may result from such minor operations as circumcision, 
hypodermic injections, the administration of antitoxin, tooth-extrac- 
tion and vaccination (95 cases), and also from major operations. 
Parturition, lack of attention to the navels of the new-born, the use 
of imperfectly sterilized cat-gut, and leech-bites or pin-pricks may 
also cause its development. Chauffard (1903) collected 18 cases in 
which injection occurred from injections of gelatin for various acute 
hemorrhages, and in 6 cases it has followed similar injections for 
aneurysm. The germ is very frequently found in gelatin, which should 
therefore be sterilized three times and in very small amounts, each 
time for thirty to forty-five minutes at 212°. H. G. Wells has placed 
emphasis on the danger resulting from the use of toy pistols and blank 
cartridges for Fourth-of-July celebrations. He noted that 39 per 
cent, of the tetanus mortality of 1903 occurred near that date; 415 



TETANUS 249 

deaths from tetanus are listed in the United States for that year as 
against 105 in 190-4; 75 per cent, of cases occur between the tenth and 
fortieth year of life. 

Incubation. — This lasts from six to twelve hours in severe experi- 
mental inoculations, from two to nine days in less intense inoculations, 
and in man, from one to sixty days. The incubation in 66 per cent, 
of the cases lasts from five to fourteen days; Rose observed that in 
33 per cent, of his cases the symptoms appeared in one, and in 45 per* 
cent, in two, weeks. 

Symptoms. — These appear suddenly, without any or with only 
indeterminate prodromes, and are due to toxaemia. This is proven 
by the fact that autopsies show no constant gross or minute altera- 
tions except those common to all convulsive conditions — e. g., points 
of congestion or punctate hemorrhage. Ehrlich's side-chain theory is 
a fairly satisfactory explanation, for the anterior cells of the cord and 
medulla combine with the toxins. Babes believed that some third 
substance formed and produced the symptoms. These are, at first, 
rigidity of the jaw ("lock-jaw/' trismus) and stiffness of the neck. 
In most animals the muscles become rigid near the seat of inoculation 
first, and sometimes, in injuries received in war, the muscles of the 
leg may be first involved. The probable explanation of this is that 
the toxin travels along the nerve trunks (Marie, Morais, Ransom, 
Meyer). The horse, like man, develops trismus first. The poison 
excites the anterior cells of the cord and medulla to tonic contraction. 

The fades tetanica results from a spasm of the zygomatic muscles, 
which produces the risus sardonicus, and imparts a smiling expression 
to the upper and a sad expression to the lower part of the face (Konig) ; 
there are folds in the forehead; the eyebrows are raised and approxi- 
mated, the eyeballs directed forward, the masseters prominent, the 
teeth set, and the nares dilated. The spinal extensors are tonically 
contracted, arching the head backward and the trunk forward (opis- 
thotonos); the abdominal muscles are hard and retracted, and are 
occasionally even ruptured by their violent contraction; in rare cases 
the contracture is lateral (pleurothotonos), or forward (emprosthot- 
onos), or the body is straight and rigid (orthotonos). The limbs are 
extended, the legs more so than the arms, and the feet and hands least. 
The spasms are chiefly tonic, but clonic exacerbations for a few seconds 
may result from peripheral stimulation of the sensory nerves or those 
of special sense, by the least touch, jar, breath of air, bright light or 
sound. The reflexes are enormously increased, particularly those 
of the skin. The spasms occasion violent muscular pain, oppres- 
sion over the lower chest and epigastrium, speechlessness, insomnia, 
and, from participation of the medulla, profuse sweats and increased 
and irregular heart action. Fever may be present (even 105° to 111°), 
or the temperature may be normal or subnormal. After death a tem- 
perature of 114° has been observed. The sensorium is usually clear. 
Evacuation of the bladder and rectum is difficult, and erection or 
ejaculation may occur. The urine is decreased and sometimes con- 



250 THE SPECIFIC INFECTIONS 

tains albumin, sugar, acetone, or indican; but increased excretion of 
urea and creatin, which might be anticipated because of the muscular 
action, is not noted. In some cases the lymph glands adjacent to the 
seat of infection are enlarged. In very rare cases the toxins cause 
death without muscular spasm; i. e., they combine with tissues other 
than the nervous system. 

Death. — Sixty-six per cent, of the cases die in a paroxysm. The 
fatal factor is a respiratory spasm, an oedema or spasm of the larynx 
or an increasing heart weakness; death from collapse or in coma is 
exceptional. 

Diagnosis. — The diagnosis is based on the nature of the wound, 
the presence of the Bacillus tetani, trismus (which is necessary for a 
diagnosis), the facies, substernal oppression, and opisthotonos. Serum 
from cases of tetanus, obtained by blistering, is fatal to white mice 
in twelve to twenty-four hours. In strychnine poisoning the history 
of the case, tests for the drug in the stomach washings and urine, the 
more abrupt onset of the spasm and of the reflex excitability, the more 
diffuse and severe clonic intermittence of the convulsions, their greater 
involvement of the hands and feet, and the later appearance of trismus 
and its interparoxysmal relaxation, are entirely distinctive. Hysteria, 
hydrophobia, and tetany (q. v.) are wholly different from tetanus. 
In meningitis the sensorium is affected. Trismus may be due to such 
other causes as dental caries or parotitis. Inflammation of the temporo- 
maxillary joint usually results in a tender area in front of the tragus, 
produces unilateral masticatory cramp and is easily distinguished by 
the clinical evolution alone. Escherich's pseudotetanus is characterized 
by tonic contractures of the jaw, the back, and the limbs, which occur 
oftener after an acute infection than as an independent disease. Con- 
valescence is usual after a few weeks. 

Prognosis. — The death-rate ranges from 45 to 90 per cent., aver- 
ages between 80 and 90 per cent., and is modified by the following 
factors : 

1. Incubation. — The later after inoculation tetanus develops, the 
better is the outlook. The mortality is 91 per cent, if it appears 
in the first week, 81 per cent, if in the second, and 52 per cent, if 
later (Rose). 

2. Site of Infection. — Infection in the arms results in a 70 per cent, 
mortality; in the legs, 90 per cent. (Norris); in cephalic tetanus (the 
tetanus facialis or kopftetanus of Rose, first described by Charles Bell, 
in 1830), the mortality is almost 100 per cent. J. H. Lloyd collected 
100 cases of this type (1905); he finds the prognosis better than in the 
ordinary tetanus; Lloyd found seven cases of facial diplegia. In this 
type there is facial paralysis and involvement of the pontine and medul- 
lary nuclei, which sometimes causes dysphagia (hydrophobic type), or 
paralysis of the eye. The author observed these symptoms in a boy 
who had been kicked over the ear by a horse. Tetanus or trismus 
neonatorum, especially described by Beumer (1887), is an infection of 
the navel which occurs in the second week of life. It prevents nursing 






TETANUS 251 

and is fatal on the third or fourth day in 83 per cent, of the cases. In 
the West Indies 50 per cent, of the children died of tetanus at one 
time, in the Western Hebrides, 67 per cent., and in Iceland, 100 per 
cent. Tetanus puerperalis, particularly described by Heyse (1893), 
is a uterine infection and usually follows difficult labor, abortions, or 
ministration by midwives, and is generally fatal. In three years there 
were 232 cases in Bombay (Gowers). 

3. Course. — Hippocrates observed that patients who survive the 
fourth day may recover; 68 per cent, of cases die in the first four days. 
According to Willard, 88 per cent, of acute and 25 per cent, of chronic 
cases die. 

4. Trauma. — The death-rate in traumatic cases is over 80 per cent. ; 
in the so-called idiopathic cases it is 50 per cent, or lower. 

5. Sex. — More women recover than men. 

6. Symptoms. — Slight trismus and response to antispasmodics are 
favorable; high fever and involvement of the pons or medulla, respir- 
atory spasm, dysphagia, and ocular paralysis, are unfavorable. 

Treatment. — 1. Prophylaxis. — This consists of general surgical 
antisepsis and special care of punctured wounds, hsematomata and 
injuries caused by blank cartridges. Iodine and silver nitrate are 
very helpful, but wide incision (in order to open the punctured wound, 
for the bacillus is anaerobic), thorough lavage and packing are most 
essential. Antiseptic conduct of labor, and care of the navel in the 
new-born, need but little emphasis at the present day. 

2. Antitoxin Therapy. — Behring and Kitasato (1880) discovered an 
antitoxin and were able to immunize animals by cultures which were 
heated from 122° to 140°, or treated with Lugol's solution, which 
changes the toxins to toxoids (Ehrlich). The antitoxin was found in 
animals which are naturally immune to tetanus, such as crocodiles 
and chickens; and it was found in the fluids (the blood, milk, and 
bile) but not in the tissues. Tetanus antitoxin is not bactericidal, — i. e., 
it does not act on the bacilli. It neutralizes the tetanus toxin in the 
blood, but not after the toxin has become fixed in nervous tissue, 
from which the antitoxin cannot dislodge it. Behring and Ehrlich 
think that the antitoxin neutralizes the toxin chemically, while Babes 
and others consider that cell metabolism is the most important factor, 
and that possibly a third substance is secreted. Tizzoni and Cattani 
(1891) produced a serum somewhat different from that of Behring. 
From the above it is obvious (a) that serum prophylaxis may be suc- 
cessful in suspected cases of earth infection or in dirty abortions, 
although the term " successful" is presumptive, as it implies that 
tetanus would certainly have developed; it has been successful in 
cases of wounds received on the Fourth of July, and it also succeeded 
in the Prague obstetrical clinic, in which latter instance every other 
measure failed; (b) that if used early it may neutralize circulating- 
toxins which have not yet become attached to nervous structures and 
(c) that when the toxins have combined with the motor cells, it must 
be ineffectual. Babes estimates the mortality at 70 per cent, even 



252 THE SPECIFIC IXFECTIONS 

when the serum is used, which confutes the alleged lowering of the 
death-rate (34 per cent., Engleman; 43 per cent., Koehler, 16 per 
cent., Behring). The first dose should be 20 to 30 c.c, and later 15 
to 20 c.c. should be given two to four times daily. It should be injected 
near the site of inoculation, and especially into the nerve trunks near 
the injury, in order to reach more readily the toxins. Subdural inocu- 
lations saved a severe case of cephalic tetanus (Holub). The technique 
is the same as in lumbar puncture (see Meningitis). 

3. Clonic Convulsions. — These may be minimized by absolute quiet 
and seclusion, by darkening the room, and by careful handling of the 
patient. Morphine may be given hypodermically to relieve pain, 
insomnia, and cutaneous reflex irritability; one-quarter grain may be 
given every four to six hours for a day or two, but the pupils of the 
eyes and the respiration rate should be carefully watched. Occasion- 
ally a corrective hypodermic of atropine should be given. Chloral 
hydrate depresses the motor elements of the cord; twenty grains may 
be given every two hours for three doses, but even this amount may 
cause dangerous cardiac symptoms in alcoholics or in cases of arterio- 
sclerosis. Digitalis may be given with chloral hydrate to steady the 
heart, and morphine and potassium bromide to enhance its depresso- 
motor action and to lessen the cutaneous irritability. The bromides 
should be given 5 ss j every three hours, for six doses, after which the 
interval should be lengthened. Inhalations of chloroform and amyl 
nitrate may inhibit the onset of severe attacks. Hot baths relieve 
tension, but the lifting of the patient apparently more than counter- 
balances their benefits. 

4. Nutrition. — This must be carefully maintained by the nasal 
catheter (see Typhoid) or by the rectum. In this way, the difficulties 
offered by trismus or dysphagia are overcome. 

5. Other Measures. — (a) J. B. Murphy performs lumbar puncture 
and injects a weak solution of eucaine and morphine, with apparent 
results; (b) Baccelli, Ascoli and Babes secure better results with 
hypodermics consisting of 10 drops of 3 per cent, carbolic solution, 
than they do with serotherapy; no ill effects were observed from long- 
continued daily use; (c) Wassermann's proposal to inject subdurally 
an emulsion of sheep brains is endorsed by Babes and others, (d) 
Meltzer has recently been successful with intraspinal injections of a 
dram of a 25 per cent, solution of magnesium sulphate. 



HYDROPHOBIA (LYSSA; RABIES). 

Definition. — An acute specific infection, of unknown causation, 
peculiar to carnivora, the bites of which convey infection to other 
animals and to man. The disease is characterized by tonic and clonic 
spasms of the oesophagus and of the respiratory muscles, which 
spread to other muscles, and by an inevitably fatal evolution. It 
was described in ancient Jewish, Egyptian, and Indian writings, and 



HYDROPHOBIA (LYSA; RABIES) 253 

was discussed by Democritus in the fourth and fifth centuries, B. C. 
The first adequate account was one by Youatt (1828, London). 

Etiology. — In Germany it is infrequent, because of the strict laws; 
from 1887 to 1894 only 16 cases occurred. In England, France, and 
America it is far more common, and in Russia many cases develop. 
Dogs are most susceptible, are most frequently affected, and are the 
chief cause of dissemination (90 per cent.); next come wolves, cats, 
and cattle; and finally skunks, horses, pigs, rabbits and even fowls 
may be inoculated. The character of the virus is unknown. It is found 
in the nervous tissues most abundantly, in the saliva, and also, though 
in small quantities, in the blood, tears, sputum, semen, urine, and 
milk, and in the adrenals, lymphatics and muscles. Its propagation 
has been held to occur along the nerve trunk, but it must also reach 
the blood current. It resists putrefaction for fourteen to twenty-four 
days but, on drying, becomes attenuated in ten to fifteen days. The dis- 
ease prevails chiefly in warm weather, particularly in the "dog days," 
and most laws are based on this assumption; but it is also fairly com- 
mon in cool weather. In Paris most cases occur in March and May. 
Sixty per cent, of cases occur in men and 40 per cent, are in subjects 
under fifteen years of age. Inoculation occurs through the skin, and 
nearly always results from bites of infected animals, which may trans- 
mit the disease even during the incubation period. Punctured or 
deep wounds, and those in the nerves or muscles are most dangerous; 
33 per cent, of those bitten by mad dogs, 62 to 90 per cent, of those 
bitten by wolves, and 60 per cent, of those bitten by cats, die. In 
exceptional cases, rabies results from being licked by an infected dog, 
from kissing an infected person, or from dissecting an infected body. 

The incubation period varies greatly, averaging from six to ten 
weeks. The extremes are from one and a half weeks to five months, 
or in exceptional cases, one or two years. It varies with (a) the age, 
being shorter in children than in adults; (b) the site of the wound. 
If this is on the face or head, the incubation is very short and the 
symptoms are very severe. The incubation is longer and the symp- 
toms less intense when the point of infection is on the body, because 
the clothing tends to clean the virus off the teeth. 

Symptoms. — Three stages are described, which are somewhat arbi- 
trary and variable. 

First or Prodomal Stage. — The scar may become tender, pares- 
thetic or painful ; the adjacent glands sometimes swell, or, if the wound 
is on the face, there may be sneezing. Distinct psychical alteration 
is usual, such as depression, irritability, or anxiety. Headache, in- 
somnia, hyperesthesia to light, sound and touch, anorexia, and some 
elevation of the temperature and pulse rate are usual. Sometimes 
speech is slightly disturbed, the voice is hoarse, the pupils are some- 
what dilated, and premonitions of the later dysphagia are experienced. 
This stage lasts from one to two days. 

Second or Excitation Stage. — (a) The excitement is more motor 
than psychical. The cutaneous and deep reflexes are increased. 



254 THE SPECIFIC INFECTIONS 

There is such hyperesthesia that the least sound or light, the slight- 
est breath of air, or food and water in the throat, induce violent reflex 
spasms, whence the patient's dread of these excitants (photophobia, 
aerophobia, hydrophobia). Tonic spasms, following attempts at swal- 
lowing affect chiefly the muscles of the mouth, the hyoid elevators, 
and the laryngeal and respiratory muscles. Even without involve- 
ment of the larynx, the respiration is labored, with irregular, jerky, 
and often deep or sighing inspirations, during which the shoulders 
are lifted and the epigastrium is protruded. The spasms may extend 
to the trunk and limbs, (b) The excitement is also psychical, and is 
marked at the time of the spasm by restlessness and often late in the 
course by delirium, or even by violent mania. Delirium tremens may 
be simulated. The mind is usually clear between the spasms. The 
patient rarely attempts to injure attendants, although such an im- 
pression may be made by the patient's restlessness, the peculiar growl- 
ing sounds occasioned by pharyngeal and laryngeal spasm, and the 
"frothing at the mouth," which is due to inability to swallow the in- 
creased flow of saliva. Other less constant symptoms are elevation of 
temperature from 100° to 103° or 105°, though some cases are afebrile; 
salivation and lachrymation; thirst; tremors, erections and ejacula- 
tions; increased pulse rate; scanty, albuminous urine (25 per cent.), 
often with casts and sometimes with sugar or acetone. The excita- 
tion stage lasts one and a half to three days. 

Third, Paralytic or Terminal Stage. — This stage is less common in 
human than in animal rabies. In animals it may be marked from 
the beginning and the other stages may be lacking or rudimentary — 
the "dumb" rabies as contrasted with the furibund type. The spasms 
and excitement cease, the pulse becomes fast, small, and irregular, 
the pupils are wide and irregular, sweating is profuse, swallowing 
becomes impossible, and paralyses develop, mono-, para-, or hemi- 
plegic, or of the acute ascending type of Landry. The sphincters are 
sometimes paralyzed. The patient dies, unconscious, of cardiac col- 
lapse, rarely of asphyxia or convulsions. The third stage seldom 
lasts more than eighteen hours. 

Autopsy Findings. — Pathologists are not absolutely unanimous in 
regard to the specific autopsy findings. Minute hemorrhages and 
special congestion of the medulla and cord mark hydrophobia as 
they do other convulsive states. Babes's rabic tubercles are aggre- 
gations of leukocytes around the vessels and nerve cells. The latter 
may degenerate. Rapid diagnosis of rabies may be made, accord- 
ing to von Gebuchten and Nelis, by examination of the sympathetic 
and cerebro-spinal ganglia, under the capsules of which are found accu- 
mulations of epithelioid and lymphoid cells. Babes considers them less 
important than the rabic tubercles. The bodies described by Negri 
and Pavia (1903) in the cell processes, may be protozoal parasites or 
artefacts. 

Course and Prognosis. — In twelve hours to ten days — on the aver- 
age two to four days — all untreated cases die, 10 per cent, in the first 



HYDROPHOBIA {LYSA ; RABIES) 255 

day, and 60 per cent, in the first three days. Laveran, Chantemesse, 
Novi, Poppi, and others report recoveries, but Hogyes' is the only 
recovery verified by inoculations of the saliva. 

Diagnosis. — The diagnosis is usually made with ease. After bites 
from supposedly rabid animals, microscopic examination can be made 
and also subdural inoculations in rabbits, which die in two to three 
weeks with the paralytic symptoms. Tetanus of the cephalic and 
hydrophobic type is easily distinguished by the invariable trismus. 
Hysteria (pseudohydrophobia, lyssophobia) in one bitten by a dog 
may at first cause suspicion but rarely any protracted doubt. The 
initial spasmodic dysphagia and irritability are not followed by the 
other symptoms and stages of hydrophobia, and the clinical evolution 
alone is distinctive. 

Treatment. — 1. Prophylactic. — In Germany, where laws concern- 
ing dogs are not only passed but are enforced, hydrophobia is almost 
extinct, while in Roumania over 100 cases occur yearly. In human 
rabies it must be remembered that the saliva is infective. 

Preventive Inoculation. — Pasteur, in 1881, found the rabic virus in 
the nervous tissues. "The virus of the street," as Pasteur called it, 
varies in virulence, and subdural inoculations from the brains of rabid 
dogs, into rabbits, killed them in periods varying from fourteen to 
twenty days. By inoculating a series of rabbits, the incubation period 
is progressively shortened to a fixed period of seven days, this virus 
being called the "fixed virus." Pasteur attenuated this virus by 
suspending the spinal cord of the rabbit in a clean jar and desiccating 
it with caustic potash. Animals were inoculated with virus which 
had been desiccated for two weeks, then with virus a little stronger, — 
i. e., with virus desiccated for ten or twelve days, until finally immuni- 
zation was secured against inoculations which would previously have 
been fatal. In 1885, human beings bitten by rabid beasts were thus 
treated by two inoculations daily, for fifteen days, and immunization 
was secured, for the slow rabic incubation gives ample time for treat- 
ment. Early treatment secures the best results. Statistics show that 
the former mortality of 80 per cent, in untreated bites in the head or 
face has been reduced to 1.25 per cent.; the mortality of 60 per cent, 
in those bitten in the hands is reduced to 0.75 per cent.; the mor- 
tality of 30 per cent, in those bitten in the covered parts of the arm 
and trunk, and of 15 per cent, in those bitten in the leg, is reduced 
to 0.25 per cent. The total mortality has been reduced to 0.5 per cent. 
Babes (1905) very rarely found, as sequences of Pasteur's treatment, 
the following: neuroses, neuritis, bulbar or spinal paralysis and Lan- 
dry's paralysis. 

2. Primary Wound Treatment. — The wound may be sucked by 
the victim, but not by any other person. It should be washed with 
strong antiseptics, burned with caustic potash, pure carbolic acid, 
or nitrate of silver, and as soon as possible should be exposed surgi- 
cally, treated with the live cautery, and packed with gauze, so that 
healing may be delayed for over a month. 



256 THE SPECIFIC IXFECTIOXS 

3. Late Treatment. — In developed cases the mortality is 100 per 
cent., whence curative therapy is out of the question. The treatment 
of the convulsions is similar to that of tetanus, and nutrition is main- 
tained by nutritive rectal enemata. Morphine and inhalation of chloro- 
form are better than chloral and bromides, and should be given until 
they show their full physiological effects. Cocainization of the mouth 
and pharynx may overcome the pharyngeal spasm incident to swallow- 
ing milk and water, and to medication. Tracheotomy is useless for the 
respiratory spasm, which reaches further than the larynx, and in- 
volves the muscles of the chest and diaphragm; and besides, it is 
maintained bv manv that the larvnx itself is not closed. 



ACTINOMYCOSIS. 

Definition. — An infection caused by the actinomyces (literally "ray- 
fungus"); it is mostly sporadic in cattle, and less frequently so in 
swine, horses, deer, or elephants; it occurs occasionally in man; it is 
rarely endemic or epidemic; it is marked by chronic inflammation 
(a) in the mouth, head or neck, (b) in the lungs, or (c) in the intestines 
or abdomen; and it usually runs a chronic course. 

History. — Von Langenbeck (1845), Davaine (1850), Laboulbene 
and Robin (1853), and Lebert (1857), observed the peculiar sulphur 
granules in the discharges of pus. Rivolta (1868) and Perroncito 
(1875), described the fungus, Bollinger (1877) first scientifically estab- 
lished its constant occurrence in cattle, and Hartz named it Actino- 
mycosis bovis. J. Israel (1878) first found the parasite in human 
cases, but to Ponfick (1879) is due the credit of identifying the bovine 
and the human types. William T. Belfield, of Chicago, first found 
actinomycosis in this country. The monographs by Ponfick, Israel, 
Bostroem and Illich are the most important. 

Etiology. — Its distribution varies. Statistics in Berlin, Breslau and 
Vienna show large numbers of cases. There are more cases in Scot- 
land, Denmark, Italy, and Russia, than in America, where it is less 
frequent in the United States than in Canada. Seventy per cent, of 
the cases occur in males, and most of them are in subjects between 
twenty and forty years of age (33 per cent, between twenty and thirty; 
82 per cent, between ten and fifty). The fungus enters the system 
chiefly by the mouth, in which ragged teeth, abrasions, etc., favor 
its access. Though almost nothing is known of it outside of the body, 
it occurs in straw, hay, barley, oats, and similar cereals, remnants of 
which are often found in actinomycotic foci. Most cases occur in 
young cattle at dentition; 89 per cent, in the last half of the year, 
when the hair and the grainVhich are ingested are dry. The drinking 
water may be the source of infection. 

Bacteriology. — The parasite of actinomycosis is classed as a strepto- 
thrix and is found in small granules which measure 0.15 to 0.75 milli- 
meters, are usually ovoid in shape, and show a "radiate" form when 



ACTINOMYCOSIS 257 

squeezed under the cover glass. The younger forms are transparent, 
sago-like, white-gray bodies which may be easily overlooked, and the 
older forms are more yellow. These suphur-like granules, on minute 
examination, consist of threads and coccoid bodies which some con- 
sider spores. The older yellow forms become clubbed, which is con- 
sidered a degenerative change. The threads divide and branch. The 
fungus is therefore phleomorphic. It stains fairly well with the usual 
stains and by Gram's method. Cultures are successfully grown in 
50 per cent, of the cases, and are best obtained by mixing the granules 
thoroughly with softened gelatin and bouillon, and then by spread- 
ing or inoculating them as usual. The colonies are thick, folded, 
membranous, resistant, and at first have a mucoid or crystalline appear- 
ance. Experimental inoculations succeed, but infection is very rarely 
direct either from animals to man or from one person to another. 

Forms of Actinomycosis. — Incubation averages four weeks. Clin- 
ically there are three main forms: (1) That of the head and neck; (2) 
that of the lower digestive tract; and (3) that of the respiratory tract. 

1. The forms localized in the head and neck constitute 50 per cent, 
of actinomycosis. The atrium is in the soft tissues of the mouth 
and throat. Entering these, the fungus is surrounded by a massive 
accumulation of round cells which soon degenerate centrally. The 
reaction of the connective tissue is marked and the proliferation 
shows numerous round or polygonal cells with large nuclei, — the epi- 
thelioid cells. Giant cells also form. The process is designated by 
Bostroem as a chronic inflammation, and by Israel as an infective 
granuloma, resembling the tuberculous, syphilitic, or leprous process. 
The further destiny of these granulations of the tissue is modified by 
the resistance of the tissues and by the animal diseased, (a) In man 
the granulation wall usually melts so that the fungus is surrounded 
by a mucoid, creamy, cloudy fluid, in which there are oil, fibrin, blood, 
pigment, and actinomycotic cocci and threads; the abscess is formed 
by the fungus itself which, unaided by pyogenic organisms, burrows 
and reaches the surface by circuitous fistula?; it discharges a thin, 
puriform secretion like that of scrofulous glands but which contains 
the sulphur-like grains. (b) In cattle and horses the granulation tissue 
is more effectually obliterative and limitative, and hard, board-like, 
or ligneous tumors develop ("lumpy jaw/' "wooden tongue"); sup- 
puration and miliary dissemination are less frequent, and calcification 
is more frequent than in man. In human subjects the infiltration 
may involve the neck, face, tongue, pharynx, tonsils, larynx, and thy- 
roid gland. In general, the most frequent involvements are inflam- 
mation of the soft tissues about the jaws, especially those under the 
lower jaw, submaxillary or submental infiltration, and superficial in- 
vasion of the bones. In the tongue, actinomycosis may resemble 
gummata or cancer but in cancer there is more pain and glandular 
invasion. In some few cases the maxillae may be primarily invaded 
(Israel, Murphy). Sarcoma and caries may be simulated. The pro- 
cess sometimes spreads regionally along the bones to the base of the 

17 



258 THE SPECIFIC INFECTIONS 

brain and results in meningitis; along the spine, and causes vertebral 
erosion; and behind the sternum with mediastinal infiltration. 

Symptoms. — These vary with the part invaded. The fever is ir- 
regular, rarely continuous or typhoidal. Pain and tenderness are not 
marked, for the process is indolent or chronic. Dysphagia accom- 
panies retropharyngeal involvement, oedema occurs in laryngeal 
localization, and other local interference such as venous obstruction is 
frequent. In a recent case, the writer observed trismus and severe 
unilateral trifacial neuralgia from a primary focus at the base of the 
skull; recovery followed operation. Besides the regional invasion by 
contiguity, above named, hematogenous extension by metastasis may 
occur in this type as well as in the others to be described later. Unlike 
tuberculosis, extension to the lymphatics, or general dissemination by 
them, is unusual. Hematogenous (really pysemic) deposits may occur 
in the brain, meninges, liver, spleen, kidneys, intestines, lungs, muscles, 
skin, bones, joints, or retinae, in which they may simulate miliary 
tubercles. In the head-and-neck form the mortality is 10 per cent. 

2. The lower digestive tract ranks next (20 to 30 per cent.) in fre- 
quency of infection. This may occur anywhere between the oesoph- 
agus and rectum, but 50 per cent, of this group occurs in the region 
of the ileum, caecum and appendix (perityphlitis actinomycotica). 
Local pain, tenderness, induration and adhesions frequently follow 
the primary lesion of the intestine. In rare instances this lesion is 
superficial (enteritis actinomycotica superflcialis , Chiari), but small 
nodes usually develop in the submucosa, over which the mucosa be- 
comes somewhat pigmented. This is followed by central softening of 
the nodes and by the development of small ulcers, the undermined 
edges and uneven bases of which make them resemble tuberculous 
ulcers. Secondary pyogenic infections are frequent. The ulcers may 
cicatrize or fuse into larger ulcerations. 

Symptoms. — As above indicated, the signs are often those of appen- 
dicitis; symptoms may be absent, but colic and vomiting are often 
present, and constipation is more frequent than diarrhoea or dysenteric 
stools. Extension of the process is usually downward; it involves the 
iliac bone, and occasionally the thigh, hip, bladder, ovaries, vagina, or 
rectum; the ray fungus is voided in the urine and faeces; and anter- 
iorly preperitoneal, suprapubic, or muscular infiltrations occur, with 
external fistulae. The process then extends backward into the retro- 
peritoneal cellular tissue, in which it may burrow around the kidneys 
or even into the chest. These varied localizations may simulate peri- 
nephritis, peripsoitis or parametritis. In rare cases, freely movable, 
and therefore operable, tumors may develop. Scoliosis may result. 
Vascular metastases may occur as they do in involvement of the head 
and neck but suppuration of the liver is the most frequent develop- 
ment, and is secondary clinically and pathologically, though it is 
sometimes apparently primary. Forty cases are reported. In 71 per 
cent, death results, usually from exhaustion, from mixed infection, 
or from diffuse amyloidosis. Diagnosis must be made from gross de- 



ACTINOMYCOSIS 259 

tection of the yellow granules or from microscopic recognition of the 
fungus. 

3. Respiratory involvement is still less frequent. It is (a) secondary 
to extension by contiguity from the neck or abdomen, or to miliary 
or larger infarcts, or (b) primary in the lungs, which is a less fre- 
quent form (14 per cent.). Primary pulmonary actinomycosis is 
rarely of the superficial type (bronchitis actinomycotica super ficialis) . 
Canali described such a case with seven years duration. This form 
may easily escape recognition. A case of actinomycotic fibrinous 
bronchitis is reported. More often it is deeper, and invades the alveoli. 
The lower lobes are its usual seat and they show a gray hepatization 
with the ordinary actinomycotic changes. Fusion of the foci may in- 
volve large portions of tissue, but demarcation is usual in the lung. 
The clinical picture varies, (i) In some instances cavity formation is 
obviously present. There is fever of a hectic or possibly of a typhoid 
type, an harrassing cough, and malnutrition; the sputum is puriform, 
sometimes foetid and stained with altered blood like raspberry 
jelly, or contains even considerable quantities of blood and 
often reveals the actinomycosis rays, (ii) Induration of the lower 
lobes may occur from cicatricial development, (hi) Pleurisy; (iv) 
peripleuritis; (v) pericarditis; or (vi) mediastinitis may be the domi- 
nant finding. There may be much luxation of the intrathoracic con- 
tents, and involvement of the heart is characterized by great dyspnoea, 
dilatation and hydrops. Penetration may occur through the chest 
wall with characteristic discharge from the sinuses which run along 
the spine and ileopsoas muscle, or into the abdomen. Hematogenous 
generalization occurs as in other forms. The examination of the spu- 
tum is essential for diagnosis unless fistulse develop. In 25 per cent, 
of cases the ray fungus is seen and tuberculosis is excluded by absence 
of tubercle bacilli and elastic fibers. Otherwise the resemblance may 
be very close or differentiation impossible. The course is usually sub- 
chronic (averaging under a year), less often chronic (two to three 
years), and very rarely acute. The outcome is fatal in practically 
100 per cent, of the cases, though Schlange reports two recoveries. 

4. Other primary localizations are rare; 23 primary skin cases are 
reported. They may resemble lupus or tubercle. Primary brain 
lesions are infrequent (Bollinger, Orlow, Keller, Grangee and Del- 
vaine); they may simulate brain tumor or cause cortical epilepsy. 
Primary genito-urinary infection is possible, though very few cases 
are recorded (Stanton). The lachrymal duct or middle ear is very 
rarely the primary focus. 

Diagnosis. — Similar fungi may cause difficulty in diagnosis, but 
their classification is still a mooted question. Eppinger's cladothrix 
asteroides may cause deposits in the cervical glands or brain, and 
miliary nodes in the lung. Rosenbach noted a similar growth in 
erysipeloid, and Vincent in Madura foot, which liquefies gelatin and 
produces a red pigment. The leptothrix of the mouth is a possible 
cause of confusion. 



260 THE SPECIFIC INFECTIONS 

Treatment. — 1. Prophylaxis. — Besides general measures employed 
in any contagion, care is necessary in regard to the holding of straws 
in the mouth or picking the teeth with them. Thorough cooking of 
cereals before eating is essential. 

2. Surgical Extirpation. — This is indicated, if possible; or a sharp 
spoon should be used to clean accessible foci and fistulse, which should 
then be packed with iodoform or sublimate gauze. Injections of 
bichloride of mercury (^ per cent, to 1 per cent.) are used especially 
by Illich and Hochenegg. 

3. Potassium Iodide. — In cases wholly inaccessible to the knife, 
potassium iodide is excellent or even specific, according to some 
writers. It is not parasiticidal, but softens the tissues. It also pre- 
pares operable cases for surgical measures; 53 per cent, of bovine 
cases recover under its use. Thomassen and Netter use six grams 
daily for a month and then decrease the dosage. Rydygier injects 
large quantities of a 1 per cent, solution into the affected tissues. 

4. Tuberculin Injections. — These were advantageous when used by 
Billroth, Kahler, and Socin. Bevan has seen benefit result from the 
internal use of copper sulphate. 



GONORRHEAL INFECTION. 

Lightly spoken of as "the badge of virility," gonorrhoea is often 
untreated and neglected. It frequently becomes chronic, and in its 
so-called latent form may be conveyed after marriage to the wife, on 
whom it usually entails suffering, frequently sterility, and sometimes 
permanent invalidism. Its other dangers are: 

I. The regional invasion of the genital tracts (a) in the male, of 
the prostate, seminal vesicles, and testes; (b) in the female, of the 
vagina, cervix, uterus, tubes, ovaries, and peritoneum; in institutions, 
repeated epidemics of vaginitis in children have occurred; (c) in both 
sexes, of the bladder, pelvis, and kidneys, in which extension, mixed 
infection is an important factor. 



II. Gonococcic Septicopyemia. 

Hematogenous generalization has already been discussed under 
septic affections. The fever is toxsemic and septicemic. Injection of 
sterilized cultures produces violent reaction, which hitherto has baffled 
attempts at animal immunization. The fever is intermittent, and is 
often marked by great variations. The gonococcus has been found in 
the blood (Amann, Petrone, Hewes, Thayer, Benmer and Lazear, in 
all 15 times); in the myocardium (Councilman); in the pleura (15 
cases collected by Lemoine and Gallis, 1905); and in the joints (v.i.), 
kidneys, spleen, muscular abscess, lymph-glands (von Hausteen, Col- 
umbine) and skin (Hochmann, Horwitz, and Rendue). It has also 



GONOCOCCIC SEPTICOPYEMIA 261 

been found in meningo-myelitic foci; in muscular abscesses; in 
myositis (7 cases collected by Harris and Haskell, 1904); in arteritis 
and phlebitis (25 cases collected by Heller, 1904; the author saw one 
in 1905 with Dr. Cuthbertson) ; in purpuric, erythematous, dermatitic 
and exanthematous eruptions; in felons; and in periostitis. It is 
reported to have been found in cases of pneumonia and of multiple 
neuritis. Lceb's collection of 62 cases of ulcerative gonorrheal endo- 
carditis has been referred to. This endocarditis may possibly heal. 
Septicopyemic lesions may be due to Neisser's diplococcus alone, or 
to mixed infections. 

Most cases of gonorrheal rheumatism must be regarded as a mild 
septicemic form. Occasionally it is part of a severe septicopyemia. 
It was described by Selle and Swediaur in 1781, and the gonococcus 
was first found by Petrone (1883), and Kammerer (1884). According 
to Damasch it develops in 2 to 3 per cent, of gonorrhceal infections. 
If 80 per cent, of males contract gonorrhoea, Konig's assertion that it 
is the most common disease of the joints seems well established. 
Eighty per cent, show an acute urethritis; in the balance the urethritis 
has subsided or become chronic. In 18 cases reported by Lucas, the 
infection was primarily gonorrhceal conjunctivitis, especially in in- 
fantile cases. Northrup's series of 252 cases of gonorrhceal rheuma- 
tism gives 91 per cent, in males, though Brun and Bennecke find 62 
per cent, in women, which is contrary to common experience. About 
50 per cent, of the cases occur between twenty and fifty years of age. 
It has followed experimental gonorrhoea. Too active treatment and 
sexual indulgence during the florid stage of gonorrhoea are held to be 
predisposing causes. 

Symptoms. — The symptoms are extremely variable. The joints 
alone may be involved, or there may be more severe evidences of blood 
invasion, such as endocarditis. While the synovial membrane is most 
often inflamed, gonorrhceal rheumatism is more than synovitis. The 
accessory burse, contiguous tendon sheaths, and the extracapsular 
structures are often involved, whence the name of gonorrhceal arthritis. 
It is often held that it affects one joint (monarticular) or at least few 
joints (oligarticular). Though fewer joints are usually involved than 
in genuine rheumatism, in Northrup's series more than one joint was 
affected in 78 per cent, of the cases, and three or more joints in 69 
per cent.; and in Gerhardt's series two to nine or more joints were 
involved in 87 per cent., and one joint only in 13 per cent. Gonor- 
rhceal arthritis frequently involves joints which are usually unaffected 
in acute articular rheumatism, e.g., the sacro-iliac synchondrosis, 
sternoclavicular, temporo-maxillary, and intervertebral joints. The 
knee is affected in 70 per cent., the ankle in 27 per cent., fingers and 
toes in 19 per cent., hip in 13 per cent., wrist in 12 per cent., shoulder 
in 10 per cent., and the elbow in 9 per cent., of the cases. Within the 
joint serofibrin exudes, and without the joint there is oedema and infil- 
tration. Suppuration is not frequent but may occur with or without 
coincident pyogenic infection, especially in the joints and tendons of 



262 THE SPECIFIC INFECTIONS 

the hand. The gonococci are found with variable frequency, the high- 
est percentage of cases being that of Rindfleisch (60 per cent.). 

Konig's pathological classification includes (1) simple hydrops of the 
joint; (2) catarrhal or serofibrinous hydrops; (3) pyarthrosis, and (4) 
gonorrheal phlegmon, affecting the soft parts. A clinical classification 
may be made as follows: (1) Arthritic form, pain with exudation; (2) 
acute or subacute polyarthritis, by itself, or with septicaemia; (3) 
polytendosynovitis and polybursitis, often with periostitis, — this is the 
periarthritic form; (4) acute monarticular form, with rather intense local 
reaction, sometimes with suppuration; and (5) the chronic monartic- 
ular hydrarthrosis, especially of the knee, a far less frequent form. 
We might add (6) the forms in which simple arthralgia is present or 
the process localized in the heel. 

The great clinical variations are explained by Pribram, as follows: 
The joint involvement results from (1) gonorrhoea alone; (2) gonor- 
rhceal infection plus mixed infection, with pus or tuberculous micro- 
organisms; (3) genuine rheumatism, associated with an accidental 
and essentially insignificant gonorrhoea; (4) gonorrhoea plus a relapse 
of rheumatism. 

Course. — The course is essentially chronic, is sometimes relapsing, 
and is marked by complications; iritis is fairly frequent; atrophy in 
the contiguous muscles may occur as in rheumatism; ankylosis may 
result, which is far oftener plastic than osseous. In exceptional in- 
stances, sciatica, permanent arthritic changes resembling arthritis de- 
formans (q. v.), exhaustion psychoses, or multiple neuritis, develop. 

Treatment. — Recovery is a matter of time and nature, rather than 
of therapy. The salicylates are almost wholly inert and the iodides 
highly unsatisfactory. In the acute stage, immobilization by plaster 
casts or splints, and in the chronic stage, blisters, Pacquelin cautery, 
massage, passive movements, and extension, to overcome residual 
exudation and contractures, are useful. Some cases are helped by 
Roentgen rays and by superheated air (See Arthritis Deformans). 
Surgical incision and simple irrigation are indicated after a reason- 
able lapse of time and after the failure of expectant treatment. In 
some intractable cases, however, there is no fluid to drain. 



SYPHILIS (POX, LUES VENEREA). 

Syphilis is evidently an ancient disease as is indicated by probably 
syphilitic bones belonging to the stone age and found in Japan. The 
first clear outbreak occurred in 1494 among the troops of Charles 
VIII, who was then investing Naples. A full account of this disease 
will be given because of its colossal importance. 

Definition. — A specific chronic infection, found in man only, either 
hereditary or acquired by inoculation, in the seat of which a primary 
lesion (hard chancre) develops. This is followed in two or three 
months by secondary lesions in the skin and mucosae. Still later (after 



ACQUIRED SYPHILIS 263 

months or years) tertiary lesions (gummata) develop in the viscera, 
bones, and skin, and these are finally followed in some instances by 
meta- or parasyphilitic manifestations, as tabes dorsalis, dementia, 
and perhaps aneurysm. This division of Ricord is most convenient 
but does not invariably hold, — e.g., in hereditary syphilis and some- 
times in the (malignant) acquired variety, where the stages overlap. 
Virchow finds a close histological resemblance between the secondary 
and tertiary lesions. 

Stages According to Ricord. — The Primary Stage. — (1) Incubation 
lasts until the chancre appears, when the disease is already, according 
to most writers, a general disease; (2) the chancre develops, the lymph- 
vessels and adjacent glands enlarge, and there is a period of latency, 
sometimes called the "second incubation." 

The Secondary Stage. — (1) Symptoms prodromal to the eruption, 
as fever or anaemia, develop and then (2) the eruption appears on the 
skin and mucosse, with headache, " rheumatism," iritis, or sometimes 
jaundice, albuminuria, and splenic tumor. 

The Tertiary Stage — This may follow very closely upon the second- 
aries or appear with them (syphilis maligna), but usually is not mani- 
fest for at least two years (even fifty or sixty). Tumor-like gummata 
occur in the skin and viscera, especially in the liver, scrotum, brain 
and cord. Unlike secondary manifestations, they are asymmetrical, 
non-contagious, and respond to different therapeutic agents. 

The parasyphilitic manifestations of Fournier, Sigmund, Lancer- 
eaux and Baumler are not included in Ricord's division. 



Acquired Syphilis. 

Etiology. — 1. Transmission by sexual intercourse (contact syphilis) 
causes the great majority of cases, but the term lues venerea is often 
incorrect and unjust since syphilis may occur in the innocent (syphilis 
insontium). Lustgarten's bacillus 3 to 4 p. in length, found by him 
in round cells of primary and tertiary lesions, is not generally recog- 
nized and may be confused with the smegma organism. Schaudinn 
and Hoffmann describe a spirochcete pallida, so named because of the 
difficulty in staining it: it is thread-like, refractile, actively mobile, 
pointed at its ends, and twisted like a corkscrew; it measures 4 to 20 pt 
in length; it rather resembles the spirochete of relapsing fever but 
is a flagellated protozoon. Though it is clearly present in nearly all 
cases, it is not positively known whether it is the cause of syphilis or 
only a concomitant infection. It is found in the chancre, in the papules, 
blood, viscera and in inoculated apes and mice. Siegel's staining 
technique; an old, " well-ripened " solution of 1 part methylene blue 
with 2.5 parts borax and 100 parts distilled water gives clear, well- 
defined views of the parasites after ten minutes contact with the sec- 
tions, followed by simple rinsing under a strong stream of water. 
This stains the red corpuscles well, but leaves the blood plasma color- 



264 THE SPECIFIC INFECTIONS 

less, in which the parasites stand out distinctly. It is not necessary 
to examine sections of the organs, as the parasites are found equally 
well in the blood, which is much more convenient for examination. 
Siegel found the parasites constantly in the blood at the time of the 
exanthem. The parasites vanished from the blood in the third week 
of inunction treatment. 

The sound skin and mucosse resist infection, and hence a raw sur- 
face, erosion, wound, or hyperemia is necessary for infection. Syphilis 
not only has a certain choice of place in its inoculation, but persists 
with peculiar obstinacy in certain localities, notably in the genitalia, 
under the breasts, in the axilla, in the navel, between the toes, in the 
angles of the mouth, on the tongue, iris, palate or tonsils, because of 
(a) irritation caused by the sweat, sebum, saliva or urine; (b) pressure 
on the parts by clothing; (c) trauma to the skin, or (d) irritation from 
smoking, from other skin lesions, and from various causes. These 
foci are of great moment in the awakening or reproduction of the dis- 
ease. Syphilis is sometimes called a disease of cities; though more 
common in the city than in the country, syphilis very frequently 
escapes recognition in the country. 

2. Accidental infection occurs in surgical or obstetrical practice, in 
skin-grafting, by postmortem infection (two cases of personal obser- 
vation), in ritual circumcision, in nursing, vaccination, kissing, from 
use of pipes, in shaving, by scratches, from instruments used in glass- 
blowing, or from catheters. A few instances are known of transmis- 
sion through a third healthy person. 

Symptoms. — 1. Primary Stage. — After an incubation of two to 
three weeks (ten to seventy days), the initial lesion occurs (the ulcus 
durum, Hunterian chancre, or initial sclerosis). Multiple lesions are 
rare. The induration may be irregular or flat, but is usually oval. 
It is always sharply localized, is of variable or even cartilaginous hard- 
ness, is freely movable, and is usually red and papular. Hardness is 
its most constant characteristic; it may last a long time, and heals 
only when the hardness disappears. It cannot be diagnosticated before 
the sixteenth, and is most characteristic on the twenty-first day or in 
the fourth week, when the glands become somewhat enlarged. Such 
retrogressive changes as ulceration, loss of epithelium, or necrosis are 
frequent. The ulcer varies in size, is round, elliptical, slit-like, or 
irregular; it is hard, with even surface, seldom with elevations or ex- 
cavations; it has no areola, but a smooth, glistening base and there 
is some thin secretion. The color varies. It is gray when the exudate 
is removed, red, blue, or even gangrenous. On the skin the chancre 
may appear as an erosion. Contact ulcers around the corona are hard. 
The sclerosis may resemble herpes, but there is no itching. It has a 
copper hue. An herpetiform sclerosis becomes indurated in about six- 
teen days, while simple herpes lasts but three or four days. Herpes 
may be the atrium for syphilitic inoculation. If the sclerosis occur 
on a mucous surface there is little elevation; maceration and bleed- 
ing readily occur, (a) The genital sclerosis in men occurs on the 



ACQUIRED SYPHILIS 265 

urethral orifice; in the fossa navicularis, possibly producing some 
stenosis or ulceration, with a thin, "meat juice" secretion; on the 
glans, often as an erosion, usually not extensive, and difficult to diag- 
nosticate because of the hardness of the glans; on the corona, circular 
and hard; on the (broken) frenulum or on the sulcus coronarius, 
usually with ulceration and much induration, giving the " split pea" 
appearance, one-half lying on the glans and the other half on the pre- 
puce; on the prepuce, often with phimosis; on the dorsum. (6) The 
genital sclerosis in women occurs mostly on the labia; in the labia 
majora, as large, readily ulcerating contact ulcers with inflammatory 
oedema; in the labia minora as small, hard and circumscribed nodes; 
on the prepuce as hard fissures; in the urethral orifice with widening 
and induration which is felt from the vagina; on the posterior com- 
missure, as erosions, which are especially prone to infect during coitus; 
on the hymen relics, as fissures, or large hard ulcers reaching into the 
vagina; rarely in the vagina, because of its paucity in glands and the 
thick epithelium, although sclerosis may develop on gonorrhceal ero- 
sions; in the vaginal portion of the cervix, usually in women who have 
been pregnant, in which location it produces chancres on the male 
meatus and is difficult to differentiate from simple and gonorrhceal 
erosions, (c) The perigenital sclerosis occurs on the scrotum, on the 
mons veneris, or on the inner thigh, (d) Extragenital scleroses (3 to 
4 per cent.; 5.5 per cent., Montgomery and Bulkley; 6.3 per cent., 
Fournier) are especially dangerous in midwives, physicians, and wet- 
nurses. They occur on the scalp, conjunctiva, nose, eyelids, lips, 
tongue and tonsils (from sexual perversion), cheeks, fingers, arms, and 
mammae. In rare cases of accidental syphilis the chancre may not be 
found. Among 9,058 extragenital chancres, 1,863 occurred from vac- 
cination, 745 from cupping or phlebotomy, 179 from circumcision, 
and 82 from tattooing (Bulkley). 

The primary sclerosis is always inoculated from a chancre or from 
an individual with secondary syphilis, and, in very rare cases only, 
from tertiary syphilis; Delbanchs reports five infections from gum- 
mata chiefly of the genitalia. When the sclerosis is recognized, the 
blood is already infected. 

Histology of the Sclerosis. — The round cells about the vessel 
walls increase their thickness ten- or twentyfold, and the vessel lumen 
is narrowed from external pressure and endothelial proliferation, even 
to obliteration, when retrogressive change, as ulceration, ensues. The 
lymph vessels and glands are involved later. The nerve fibers are 
altered. Epithelioid and giant cells, and proliferation of the connective 
tissue in and about the vessels, are noted. The spirochete pallida is 
almost invariably present. 

Course. — Retrogression usually occurs and the induration dis- 
appears in thirty to ninety days, generally without scar formation. 
In exceptional cases (1) the sclerosis lasts longer, especially on the 
corona or prepuce, and relics may be found after years (even 50) due 
to permanent vascular injury; (2) acute or (3) phagedenic inflamma- 



266 



THE SPECIFIC INFECTIONS 



tion sometimes intervenes. Recently anthropoid apes have been inoc- 
ulated by MetschnikofT and Nicolle; they developed typical chancres 
but usually died in the secondary stage of the disease. Siegel states 
that he has succeeded in inoculating rabbits and white mice. 

Diagnosis (According to Neumann). 
Chancre or Sclerosis — vs. — Venereal Ulcer or Chancroid. 



Three days. 

Pustule, ulcer, etc., without induration, 



Incubation: two to three weeks. 

Form', erosion, ulcer, nodule, papule, 
all indurated. 

Number: single, rarely multiple at 
first, also rarely successively inocu- 
lated. 

Depth: erosion is superficial, flat, with Through entire cutis or mucosa; 
little elevation, rarely deep excava- "punched-out" appearance, 

tions. 



Often multiple at beginning or succes- 
sively inoculated. 



Border: gradual descent. 

Surface: red, livid, sometimes pseudo- 
membranous, thick, yellow-white 
covering or crusts. 

Induration: marked, cartilaginous, 
sharply outlined, movable, sometimes 
thin, lasting weeks, perhaps months. 

Secretion: scanty, serous, autoinocula- 
tion difficult. 

Pain: little. 

Destruction: rarely phagedenic (and 
then circumscribed). 

Re-infection: extremely rare. 

Lymph-vessels : inflamed frequently, 
hard and wide. 

Lymph-glands : regional, indolent, 
swelling hard, painless, movable; 
rarely pus formation. 

Nature of the disease: constitutional 
symptoms follow, usually inside of 
eight weeks. 



Abrupt, sharp, indented, undermined. 
White, gray. 



No basal induration; not sharply out- 
lined; merges gradually into adjacent 
tissue; short duration. 

Rich, purulent, auto-inoculation easy. 



Much. 

More often phagedenic; diffuse. 

Frequent. 

Painful; cylindrical. 



Often absent or acute inflammatory 
swelling; often pus formation, capa- 
ble of autoinoculation. 

A local infection, or involving at most 
contiguous lymph-glands. 



Mixed infection may occur, whence the now abandoned idea of the 
unity of all venereal ulcers. The real practical lesson from this doc- 
trine is diagnostic reservation, which is often imperative for some 
time in doubtful cases. 

Lymphangitis syphilitica is marked in 70 per cent, of cases. The 
lymph vessels may become as thick as a lead pencil, bulging at the 
site of the valves ("bubonulus"); they become hard, are mostly pain- 
less, reddened, and are narrowed in their lumen from endothelial pro- 



ACQUIRED SYPHILIS 267 

liferation, and from pressure inward of their infiltrated walls. The 
inflammation is best seen on the dorsum penis, extending toward the 
symphysis pubis; it is usually not over 6 to 8 centimeters in length, 
but may reach the glands. Resorption occurs in three to eight months. 
(Edema in women is particularly suggestive when the lymphatic sys- 
tem is involved and the initial lesion cannot be found. Local lymph- 
adenitis (indolent buboes) is present in 97.3 per cent, of cases, and 
appears in three weeks if there be much, or in four weeks if little secre- 
tion from the chancre; and in six weeks reaches the contralateral inguinal 
glands and the iliac and lumbar group, and in seven weeks, the cubital 
glands. Just before the eruption of the secondary stage, the cervical 
and other groups are involved. 

II. Secondary Stage. — Secondary symptoms usually appear toward 
the end of the eighth week (sixth to twelfth week). 1. Evidences of 
general infection occur. Fever is spoken of by the oldest wTiters, but 
is less frequent at the present time (20 to 33 per cent.). It may be 
low. It is far less common in tertiary than in secondary syphilis 
(" fever of syphilitic invasion"). It often develops just before the 
eruption, and occurs mostly in the pustular variety. It may be 
continuous, remittent, or intermittent. Solution by crisis has been 
observed by Gunz. Fournier described a typhoidal type. Janeway 
reports instances resembling tuberculosis pulmonalis. It may occur 
with chills, suggesting malaria. Sudden anaemia, vasomotor symp- 
toms, psychical depression, (frontal) headache, vertigo, neuralgias, 
palpitation, night-sweats, boulimia, polydipsia, digestive disorders, 
nocturnal boneaches, synovitis, increased reflexes, icterus, swollen liver, 
albuminuria, or swollen spleen, may also occur as prodromata. 

2. The exanthem is polymorphous, sharply marked, frequently 
grouped in a circular arrangement and is without pain or itching; it 
is highly infective, is not reddish as in other eruptions but copper- 
colored, a fact recognized in the fifth century; it appears where other 
eruptions are rare, as on the forehead or nasolabial fold; crusts may 
develop on an infiltrated basis. It is recurrent and responds to anti- 
syphilitic treatment. The most frequent form is the macule or roseola, 
next the papular syphilide, and then the forms resembling pustules, 
varicella, pemphigus or impetigo. In the folds or damp parts of the 
skin the so-called mucous patches appear, as at the angles of the mouth, 
the groin, or the perineum. 

3. The enanthem on the mucous membranes is observed on the 
tongue, lips and cheeks {mucous patches), and is often accompanied 
by pharyngitis. 

4. The lymphatic enlargement becomes general, although in some 
cases it may remain more or less localized. Syphilitic rheumatism 
and iritis are frequent. 

III. The Tertiary Stage. — This is characterized by the gumma 
which occurs in many tissues. Its specific symptomatology will be 
described below. The gumma may be microscopic, or an inch or 
more in diameter. On section it is usually hard, grayish-yellow, homo- 



268 THE SPECIFIC INFECTIONS 

geneous, centrally caseous and peripherally fibrous. Balimler first 
remarked that tertiary syphilis, particularly of the viscera (liver, etc.), 
may be attended by fever. It must be borne in mind that in 20 to 40 
per cent, of the cases of tertiary syphilis, no evidence of earlier lesions 
can be found. The author believes that this explains many instances 
of the so-called mendacia syphilitica, since there is no good reason 
why a patient should admit having gonorrhoea and lie about a 
chancre. 

Special Symptomatology of Syphilis. — (.4). Blood. — Oligocythemia 
and oligochroniaeruia occur early and may be most marked when the 
glands are widely involved (Virchow). The anaemia disappears under 
administration of mercury to reappear if too much be given. A count 
as low as 1,700,000 may be observed. The "Justus test" is based 
on the loss of red cells after mercurialization; its value is still 
undecided. The haemoglobin is reduced 15 to 30 per cent, and the 
loss may exceed that of the red cells. The white cells are increased, 
especially the lymphocytes; the eosinophiles, as in other skin diseases, 
are increased, but not constantly. The blood contains, especially dur- 
ing the secondaries, the syphilis virus, which is, however, not always 
inoculable; it has been held that the germ is a tissue rather than a 
blood parasite but recent studies have shown that the spirochete is 
usually present in the blood. Pernicious anaemia and leukaemia may 
sometimes follow syphilis. 

(B). The Skin. — The macular (roseolous) syphilide is the most fre- 
quent secondary eruption. It develops rapidly, lasts eight to ten days, 
varies in size from that of a lentil to that of a dime, is at first red, then 
livid, and pressure leaves it yellow. It comes out more clearly by chil- 
ling the skin, and sometimes after administration of mercury. It occurs 
mostly on the trunk. The face, hands, and feet are usually free except 
in severe cases. It is symmetrical, appears mostly on the flexor sur- 
faces, is circumscribed, recurs more frequently than does any other 
variety, and is prognostic-ally favorable. It is recognized with difficulty 
when sweat or other secretions cause maceration. On the scalp focal 
falling of the hair results. Annular or gyrate forms may occur. Some 
pigmentation is left. 

The papular syphilide presents various forms: (a) The small mil- 
iary papule 'lichen syphiliticus), usually develops on the forehead, 
chin, nose, shoulders, buttocks, back, and extensor surfaces of the 
extremities and usually corresponds to the glands of the skin. Ir- 
regularly distributed, it may appear in rings or circles. At first red, 
it rapidly becomes brownish-red. It may occur with the roseola or 
with acne in weak or alcoholic subjects. Fine scales or crusts may 
form, which, on falling, leave a lacquered appearance; vesicles may 
form. Recurrences are infrequent. It must be differentiated from 
psoriasis, the development of which on the scalp, ear, and extensor 
surfaces is not observed in syphilis, where the scales are smaller and 
less glistening; the hemorrhage on their removal is parenchvmatous 
and not punctate; the glands are swollen; and the hair thinned. On 



ACQUIRED SYPHILIS 269 

the palms of the hands and soles of the feet differentiation may be 
difficult, but in syphilis the centre of the papule is likely to be sunken. 
(b) The large papular syphilide is often associated with fever, constitu- 
tional disturbance, or rheumatism, and may occur on all parts of the 
body, as the corona veneris on the upper forehead, around the nose, or 
in the furrows of the chin and neck. Though infrequent on the palm, 
it is often seen on the dorsum of the hand. This variety occurs most 
frequently at the junction of the skin and mucosa and its polymorph- 
ism is pronounced, as psoriasis palmaris, rhagades, onychia, or verru- 
cose forms, (c) The condylomata latum (moist papule) is the papule 
altered by secretions or excretions, and is found about the genito-anal 
regions, axilla?, etc. It is the most important syphilide, and plays an 
important role in the propagation of syphilis by its occurrence on the 
lips, breast, and genitalia; it is flat, elevated, dirty, ill-smelling, and 
secretes a highly infective secretion, (d) The pustular syphilide in- 
cludes the acne form, the varioloid, varicelliform, impetiginous, and 
other forms. 

Gummata of the skin are asymmetrically disposed; are cutaneous 
or subcutaneous, involving deeper structures; are non-infective com- 
pared with the secondary eruptions; are prone to develop at the site 
of secondary involvements; occur in the skin more than in all other 
localities combined; follow incomplete mercurial treatment; are pro- 
moted by vicious habits and constitutional diseases; and are seen in 
6 to 13 per cent, of cases, most frequently in the third year after infec- 
tion. Small gummata may resorb by fatty degeneration, but the larger 
ones caseate, ulcerate, suffer secondary infection, and leave a scar 
with deformation. The ulcers may remain open and resemble 
lupus. Gummata are differentiated from malignant ulcerations by 
the absence of lymph nodes, by their slow growth, painlessness, and 
multiplicity, and by the results of therapy. In gumma, ulceration is 
more rapid than in lupus; it is deeper, less sharply marked, redder, 
and less symmetrical; recurrence after cicatrization is less frequent, 
the scars are less flat and smooth, and the bacteriological findings 
of lupus are absent. 

Leukoderma syphiliticum is observed in recent, but rarely in late, 
syphilis — e.g., after macular or lenticular syphilides — as white spots 
with peripheral brown pigmentation, appearing mostly on the face 
and neck. Leukoderma usually disappears in from two to twelve 
years, is rarely seen in either extreme of life, and occurs in 4 per cent, 
of syphilitic men and 45 per cent, of syphilitic women (Neisser). 

The hair falls out except from the crown of the head. This occurs 
most frequently during the secondary stage, and is proportionate to 
the intensity of the eruption. It sometimes happens during the ter- 
tiary stage; is greater in poorly nourished cases, and its regrowth is 
often imperfect. 

The nails are sometimes affected. Onychia syphilitica occurs par- 
ticularly in women, in whom it may be the only secondary symptom 
(Jullien). The nails may hypertrophy, fall out, or fail to grow. Peri- 



270 THE SPECIFIC INFECTIONS 

or paronychia rarely occurs without other specific signs and rarely 
causes pain, ulceration or suppuration. 

(C). Lymph Glands. — The inguinal glands are first enlarged because 
they are nearest to the most common genital chancre. Some glands 
are more involved than others, yet adenopathy in secondary syphilis 
of any particular group, as the epitrochlear, is not pathognomonic. 
The posterior cervical glands are involved more than the anterior. 
Next in frequency are the axillary, epitrochlear, and those along the 
pectoralis. Inflammation and pain are rare, and suppuration occurs 
in but 3 per cent. Secondary infection sometimes causes painful in- 
guinal swelling. In extragenital sclerosis, other glands are enlarged 
first, — e. g., the anterior cervical, from chancre of the lip. The glands 
are freely movable ; may remain swollen for years ; and are not usually 
larger than a hazelnut, but occasionally become massive from trauma, 
scrofula, or gumma formation, and then may resemble Hodgkins' dis- 
ease. Virchow describes three stages: (1) irritative; (2) medullary, 
with leukocytosis, chlorosis, and increase in the stroma and lymph- 
adenoid tissue; (3) caseous, from loss of water and fatty retrogression, 
and much resembling gummatous formation. 

(D). Gastro-intestinal Tract. — On mucous membranes the eruption 
(enanthem) is not necessarily characteristic, is less frequent and is less 
polymorphous than on the skin, with which it occurs synchronously. 

Mouth. — This is more involved than any other part except the skin, 
Mechanical, thermal, chemical, and bacterial irritation promote erup- 
tions. Recurrence is very frequent. The eruption sometimes occurs 
earlier than that in the skin. 

1. Erythema may occur as diffuse or circumscribed maculae, which 
are dark red with slight swelling and elevation, especially in the cheek, 
pharynx, uvula, palate and tonsils — the acute syphilitic angina; it 
rarely passes in front of the border of the soft and hard palate, and it 
often escapes recognition in women, in drinkers, and in smokers. 
Desquamation, infiltration, fissures, with a slightly granulated and 
vesicular appearance, may develop. Erosions may last long in users 
of tobacco and of alcohol. 

2. Mucous patches develop just before or with the exanthem, and 
are seen mostly on the tonsils, cheeks and lips. They are single or 
multiple, disseminated, round, elliptical or irregular, flat or slightly 
elevated patches which are circumscribed and of variable color, white, 
milky, or red. On the lips they may measure 6 to 17 millimeters. 
The desquamated epithelium may be renewed when little irritation 
exists, but the course is usually chronic; the patches swell, become 
granular, ecchymotic, and often ulcerated. On the tonsils, for instance, 
they may simulate diphtheritic patches, and in smokers a cure cannot 
be effected until the habit is stopped. Cauterization leaves scars. 
They are the most important syphilide because so highly contagious. 

3. Chronic angina occurs in addition to the syphilitic patches. It is 
of a light red, granular appearance, and is accompanied by hyper- 
semia, some oedema, and erosion, a gray coating on the swollen ton- 



ACQUIRED SYPHILIS 271 

sils, and the general appearance of pharyngitis granulosa. Psoriasis 
lingua? is usually central, with round or elliptical bright red, flat spots, 
with thread-like coating; fissures are frequent on the edges of the 
tongue, and result especially from the use of tobacco and from bad 
teeth. 

4. P achy derma, ichthyosis, and leukoplakia occur on the mucosa of 
the cheeks, and on the angles of the mouth, lips, and tongue, and are 
not always syphilitic, as Kaposi maintained. They are swellings with 
fissures, are gray in color, irregular, they vary in shape and size, and 
are thick and scar-like. They may occur early or late, especially in 
users of tobacco and of alcohol, and rarely in women. They may 
become carcinomatous. Leukoplakia in tobacco users usually occurs 
on the tongue, or under the lip or palate, while in syphilis it is mostly 
on the cheek. 

5. Gummata of the oral cavity are tertiary. They appear on the 
lips, when the face is involved, as ulcers, nodes, or deformations. In 
general they are rare and without glandular swelling, and occur chiefly 
in smokers. Gummata of the tongue are most frequent, occurring (a) 
as a diffuse glossitis or diffuse infiltration and later as a cirrhotic 
shrinkage or (6) as circumscribed gummata on the dorsum or edges 
of the tongue, with nodes, swelling, or ulceration, and without pain or 
glandular involvement. Gummata of the palate or pharynx are mostly 
multiple, and ulceration may reach the nose, spine, base of the brain, 
Eustachian tube, or the large vessels. They are dangerous because 
they are frequently diffuse, deep, or phagedenic; they destroy the 
uvula, produce adhesions, obliterate the posterior nares or Eustachian 
tube, stenose the pharynx or draw the tongue back, thus stenosing the 
respiratory passage. In the tonsils they are very deep and may erode 
the carotid or palatine artery. Differentiation is required from tuber- 
culosis and epithelioma, in which the glands are usually but not always 
involved. The diagnosis ex juvantibus is important. Carcinomatous 
or tuberculous change in oral gummata is infrequent. 

(Esophagus. — Strictures result from deep gummata, from ulcera- 
tions in the larynx, or by extension from the bronchial or other glands. 
Differentiation is required from tumors of the mediastinum, from an- 
eurysm, carcinoma, round ulcer, and nervous dysphagia. Diverticula 
may result as in other stenoses. 

Stomach. — 1. Acute catarrhal gastritis occurs in the secondary 
stage with dyspeptic disturbances and sometimes with great thirst. 
It is usually toxsemic, and is rarely due to early organic changes in the 
liver, and other organs. 

2. Chronic gastritis is more common, in part explaining the syph- 
ilitic anaemia and tertiary malnutrition: it may result from early 
changes in the liver or pancreas. It differs in no wise from the vulgar 
chronic gastritis except in the influence of treatment. Amyloid change 
and glandular wasting are infrequent. 

3. Ulcers of the stomach are not as infrequent as is usually stated. 
Some round ulcers are syphilitic and result from syphilitic arteritis; 



272 THE SPECIFIC INFECTIONS 

Rosanow described an ulcer of eight rears standing, with nocturnal 
exacerbations, which was cured by inunctions. Lafleur recently diag- 
nosed an ulcer before operation. Lang's contention that 20 per cent. 
of gastric ulcers are specific is certainly overdrawn. Flexner has col- 
lected 16 definite cases. 

4. Gummata, described by Wagner, Lancereaux, Klebs, Cornil, 
Chiari, B. Hirsch, Galliard, Andral, and TVeichselbaum, are rare. 
They begin in the submucosa, are usually multiple, leave radiate 
scars, and differ from the ordinary round ulcer in that the latter is 
funnel-shaped and broader toward the mucous membrane, while the 
ulcer of gumma has undermined edges and is broader at its base. 

5. Hemorrhages from the stomach are most rare, and Hayem's 
case is almost unique. They may also result from cardiac, splenic, 
hepatic, or renal lesions. 

Ixtestixes. — Except for the rectal involvement, little is known of 
intestinal syphilis in the adult. 

1. Acute catarrhal enteritis occurs with gastric catarrh, and pro- 
duces icterus when the duodenum is involved; it resists treatment 
other than specific. 

2. Chronic enteritis results from stasis or from acute enteritis. In 
the syphilitic new-born, enteritis is manifested by the viscid meconium. 
It may occur with gummata, and disappears only with antisyphilitic 
treatment. Obstinate diarrhoea and stenosis may follow (Cullerier, 
Pillon, Mueller, Rieder). 

3. Ulcerations may result from enteritis in secondary syphilis, from 
gummatous and diphtheroid changes in the tertiary, and from 
amyloid disease in the tertiary or quatenary stages. Meschede col- 
lected 54 cases of ulcer in the small intestines. They occur around the 
axis of the intestine, and are characterized by productive inflammation 
about the ulcer, which prevents perforation but leads to stenosis. They 
are not frequent in the jejunum or ileum but may reach the colon. 

4. Intestinal amyloid disease is associated with amyloid of the 
liver, spleen and kidneys. The gut is pale, smooth, waxy, thick, and 
rigid, and there are atrophic folds, amyloid ulcers, obstinate diar- 
rhoea, stinking stools, and hydrops. It is most frequent in the small 
intestine and is an essentially vascular change. Amyloidosis in general 
occurs in 67 per cent, of tuberculosis, and in 21 per cent, of syphilis 
(Hoffmann). 

Rectum. — Ulceration occurs in papules near the anus, or results 
from fissures (Johnson ). Rectal disease is usually secondary by con- 
tiguity, except in cases of infection from unnatural coitus, (a) The 
presence of irritative proctitis in primary cases is not clearly proved, 
as it is secondary to fissure, catarrh, papules, or ulcerations. It is 
more frequently chronic than acute, is attended by evacuations of 
pus, which are voided alone or with the faeces, by itching, tenesmus, 
and external excoriations, by a long course, and occasionally by secon- 
dary tuberculous infection, (b) Syphilitic ulcers of the rectum are 
generally tertiary. They occur high up, extend to the colon, and often 



ACQUIRED SYPHILIS 27 Z 

produce stenosis. In 14 per cent, of cases there are plaques in the 
rectum (Lang). The occurrence of strictures without previous ulcera- 
tions is rare, although Fournier declares it possible. Perforation is 
rare. The periproctal tissues are invaded. Fistulae may develop, but 
the symptoms are less marked than in cancer or tuberculosis. They 
may increase when the ulceration is low, or when it is complicated 
with fissures. The faeces are covered with mucus and blood. Diar- 
rhoea from catarrh of the colon, myositis of the sphincter with involun- 
tary evacuations, burrowing of pus, and sepsis, necessitate at best 
a long course. Tuberculous ulcers rarely occur in the rectum alone, 
and are marked by the tubercle bacillus. In dysentery the involve- 
ment is higher up, colic is more frequent, diarrhoea is more profuse, 
and the resulting stenosis is higher in the intestine. In carcinoma, age, 
cachexia and local appearances are suggestive, but not positive criteria. 
Stricture is lower in syphilis, higher in carcinoma, and adhesions — - 
e.g., to the uterus — are more commonly carcinomatous. 

Pancreas. — Acute syphilitic pancreatitis was first noted by Rokitan- 
sky. The interstitial inflammation and sclerosis causing parenchy- 
matous atrophy is rarer in acquired (22 per cent., Hecker) than in 
hereditary syphilis. The peritoneum sometimes participates in syphili- 
tic disease of the organs which it envelops, while it is extremely rare 
as an independent disease; Lancereaux, Aufrecht and Laurenzi have 
observed gummatous peritonitis. Seropurulent, serous or localized 
adhesive peritonitis may occur, as perisplenitis, perihepatitis, peri 
nephritis, or perityphlitis. Perimetritis, salpingitis, and ovaritis are 
very rare. 

(E). Spleen. — 1. Acute splenitis, first described by Walter (1821) 
occurs in 31 per cent, of acquired and 61 per cent, of congenital syph- 
ilis. (2) Interstitial splenitis occurs less frequently alone than with 
syphilitic liver and renal disease. The organ is much increased in 
size and is hard, tender, and painful from perisplenitis. (3) Gumma- 
tous splenitis is very rare, and cannot be diagnosticated intra vitam. 
(4) Amyloidosis occurs very frequently as the "sago" spleen which 
is not necessarily very much enlarged; or as the diffuse amyloid spleen, 
which causes considerable swelling. 

(F).. Liver. — Syphilis of the liver occurs in two forms, interstitial and 
gummatous, which are often associated with perihepatitis, amyloid or 
fatty change, and sometimes also with such parenchymatous changes 
as acute yellow atrophy. (1) Interstitial hepatitis (syphilitic indura- 
tion of the liver, syphilitic cirrhosis, or granulated liver) is more fre- 
quent in congenital (in 65 per cent.) than in acquired syphilis. The 
volume of the liver is increased in children, and sometimes decreased 
in adults. The surface is sometimes even, but is more frequently 
uneven, with furrows or nodules; the edge is thin, indented, and fairly 
sharp, whereas in other cirrhoses it is rounded. Perihepatic adhesions 
to the colon, the abdominal wall, etc., are frequent, and are clinically 
evidenced by lessened respiratory excursion. The connective tissue 
forms in Glisson's capsule, follows the branches of the portal vein 

18 



274 THE SPECIFIC INFECTIONS 

into the liver (peripylephlebitis), and shows as bands of grayish tissue, 
the protruding granules representing normal tissue. The liver cells 
are degenerated, or even destroyed by the connective tissue, or by 
obliterating endarteritis of the small vessels. The atrophy is most 
marked in the anterior border of the liver and in the left lobe. The 
connective tissue is not only perilobular, but reaches into the lobes 
more than it does in alcoholic cirrhosis. In acquired syphilis the liver 
is not equally nor completely diseased, whence protrusions of the 
sound tissue are noted. New bloodvessels develop in the connective 
tissue from the hepatic artery, the hepatic veins are dilated, and throm- 
bosis may occur in the portal vein and its radicles (pylephlebitis). 

Symptoms. — The clinical development is latent or insidious, — e. g., 
without pain, ascites or oedema. The abdominal veins may be dis- 
tended; the urine is often dark, possibly icteric, with heavy sediment, 
and often with albuminuria. The concomitant splenic tumor results 
from hyperplasia, stasis, or amyloid degeneration. Ascites is less fre- 
quent and develops late, herein differing from the vulgar cirrhoses. 
It usually increases gradually. Icterus is less frequent (33 per cent. 
Leube). More bile is present in the stools than in vulgar cirrhosis. 
Gastro-intestinal dyspepsia and vomiting of blood are not infrequent. 
This form develops more often in men than in women ; is promoted by 
alcoholism; has a chronic course; and its prognosis is rather better 
than in non-syphilitic cirrhosis, since relative recovery is possible. 
When the liver is small, recovery is impossible. Death is more com- 
mon from intercurrent pneumonia, from pleurisy, from cholsemia or 
hemorrhagic diathesis. 

2. Gummatous hepatitis (syphilitic hepatitis par excellence) is more 
frequent than the first form, and occurs oftener in acquired than in 
congenital syphilis. The gummata are either miliary or large nodes. 
The surface of the liver is smooth or warty, thickened, or adherent to 
the diaphragm, or colon. The nodes vary from one to over fifty, and 
may be superficial or deep. The liver is distorted, mammillated or 
lobulated (hepar lobatum). Deep, irregular, radiating furrows are fre- 
quent, resulting from absorbed gummata, affecting either lobe, and 
occurring mostly on the anterior surface near the suspensory ligament 
(Virchow) or on the edge. In congenital syphilis gummata are often 
observed at the hilum, in the wall of the portal vein, or near the bile 
vessels. 

Symptoms. — Gummata are frequently latent — i.e., are discovered 
onlv at postmortem. Considerable pain in the shoulder or over the 
liver often results, as well as pain on motion or tenderness on pressure 
in the epigastrium or hypochondrium. Pain is due mostly to peri- 
hepatitis; a friction rub is heard when the inflammation is fresh; 
adhesions and loss of respiratory excursion result, in older cases. 
Icterus is infrequent and results from accidental gummatous compres- 
sion of the bile duct (Virchow), from perihepatitis (Lancereaux), or 
from cicatrices. When icterus exists the affection is often mistaken 
for cancer. The liver may be smaller, but usually shows furrows and 



ACQUIRED SYPHILIS 275 

nodules. Early enlargement is more frequent than in alcoholic cir- 
rhosis but a final shrinkage has been observed. Ascites is rare except 
from coincident cirrhosis, amyloid liver, or cardiac insufficiency. When 
present, ascites is usually terminal, independent of the -size of the liver, 
and is often associated with albuminuria. Splenic tumor is infrequent, 
except from gummata or amyloid degeneration in the spleen, from 
coincident liver cirrhosis, from gummata at the porta hepatis, or from 
splenic vein compression. Functional dyspeptic disturbances, bronzed 
skin (Lancereaux), hemorrhages, and inflammations of the serous 
membranes, rather infrequently complicate liver gummata. 

Diagnosis. — This depends upon other evidences of syphilis, and, 
while sometimes easy, it is often difficult or impossible. All forms 
of syphilis of the liver may remain stationary for a time (Bamberger), 
and in general a longer course is expected than in alcoholic cirrhosis. 
Oppoizer and Bachdalek mistook gummata for cancer, and the re- 
ported cases of cure of cancer by the earlier writers are clearly con- 
fusions with syphilis. Age is only a relative criterion, since cancer 
may occur under thirty years, yet most cases of syphilis of the liver 
occur under the fortieth year. Ascites, icterus, enlarged liver, and 
cachexia, may occur in both diseases, occasioning doubt and confusion. 
The nodules of syphilis are usually small but may be larger than those 
of cancer. Rapid growth is an indication of cancer; more constant 
size, of syphilis. According to Bamberger and Peiser, albuminuria 
and splenic tumor are more common in syphilitic liver. The best 
clinicians have confused syphilis with cancer, and the safest rule is 
always to think of syphilis when cancer seems the obvious diagnosis. 
Coincident amyloid disease renders the diagnosis difficult. The lungs 
are compressed in cancer more than they are in syphilis. The smooth 
edge of the liver, lack of respiratory excursion, or signs of fresh hepa- 
titis, indicate syphilis (Lancereaux and Riedel). Riedel found similar 
symptoms in syphilis and gall-stones, such as pain, fever, and tender- 
ness. Fever is not uncommon in hepatic syphilis, which may then be 
easily confused with liver abscess (q. v.). Final differentiation may be 
made ex juvantibus. (See Differential Table of Diseases of the 
Liver.) 

Prognosis. — This is more favorable than in the vulgar cirrhosis, 
for the disease lasts several years. Spontaneous recovery from gum- 
mata may result without specific treatment. Rupture into the peri- 
toneal cavity is rare. Death from cachexia and amyloidosis may occur. 

Amyloid liver (q.v.) may occur in the congenital type (Rokitansky), 
but is most frequent in tertiary acquired syphilis or as a parasyphilitic 
manifestation. Amyloidosis rarely occurs in the liver alone. 

Syphilitic pylethrombosis (See Pylephlebitis). 

Icterus, especially investigated by French writers, has been attri- 
buted to an intestinal enanthem, to swelling of the portal lymphatics, 
early hepatitis, cholangitis, injury to the liver cells, or to gastroduodena] 
catarrh. Its connection with syphilis is likely, according to Neumann, 
when no gastric symptoms precede the icterus; when the icterus de- 



276 THE SPECIFIC IXFECTIOXS 

velops synchronously with the exanthem; when the exanthem recurs 
with the recurrence of icterus; and when antisyphilitic remedies re- 
move the icterus. 

(G). Kidneys.' — 1. Albuminuria occurs in cases of recent syphilis or 
in the later ulceration. It is usually transitory and its connection with 
syphilis is not precisely known. It is thought to result from toxaemia 
or vascular changes. Its prognosis is usually good, since nephritis 
rarely follows it, but the later in the disease that albuminuria appears, 
the poorer is the prognosis. The use of small quantities of mercury 
probably does not cause it (Lang), though energetic mercurialization 
may produce albuminuria, cylindruria and even calcification of the 
convoluted tubules (Prevost and Saikowsky). 

2. Paroxysmal hemoglobinuria occurs relatively often, especially 
after mercurial therapy. The prognosis is better than in non-syphilitic 
cases. 

3. Acute parenchymatous nephritis is focal and cortical. It occurs 
with the eruption, is toxemic, and is distinctly rare (although some 
estimate its frequency at nearly 4 per cent, of the cases). When it 
develops late, from ulceration, the prognosis is unfavorable. There 
may be no symptoms; anaemia, vomiting, or other symptoms of any 
acute nephritis may be present, but uraemia is rare,, since it is a focal 
disease (Bamberger), and the greatest danger is from oedema of the 
glottis and intercurrent inflammation. 

-i. Chron ic parenchymatous nephritis may follow syphilis. Its actual 
relation to the disease and its percentage are difficult to estimate 
(0.5 per cent.). 

5. Chronic interstitial nephritis differs from the ordinary form only 
in its multiple disseminated focal involvement, which leaves scars. 
Polyuria is rarely great, casts and albumin are often present in greater 
amount, and the course is more rapid than the ordinary course of 
from three to seven years, because of marasmus, amyloid, fatty, and 
other visceral changes. It often occurs from the twenty-seventh to 
the thirty-seventh year, when arteriosclerosis is rare. There is said 
to be no hypertrophy of the heart. Bamberger found syphilis in 3 
per cent, of cases of ordinary contracted kidney, but the exact relation 
is difficult to determine. 

6. Gummata, in sizes varying from miliary to large forms, which 
are found in the cortex and sometimes in the medulla, are usually 
multiple (20 to 80) and generally unilateral. The renal tissue is 
partly destroyed. They occur especially with liver gummata, amyloid 
kidney, and chronic parenchymatous nephritis. The symptoms are 
not well defined. 

7. Amyloid kidney may occur alone, or is much more frequently 
accompanied by other renal lesions, especially contracted kidney 
(Rosenstein). It always occurs in the advanced stages with cachexia 
and amyloidosis in other organs. The specific gravity of the urine is 
higher than in the non-syphilitic amyloid kidney (Bart els). The al- 
bumin is due to vascular amvloid change, but mav be entirelv absent 






ACQUIRED SYPHILIS 277 

(Ebstein). Globulin may occur in large quantities (Senator). The 
course is chronic. 

8. According to Frerichs, Cantani, and others, syphilis is an etio- 
logical factor in glycosuria. Mercurial treatment is sometimes held 
causative. The suprarenals are rarely involved, except in congenital 
syphilis; swelling, hypersemia, fatty degeneration, gummata, inter- 
stitial inflammation, and amyloid changes have been recorded. 
Gummata have been observed in Addison's disease. Amyloid occurs 
especially in the Malpighian bodies. 

(H). Circulation. — The heart was found involved but six times in 
100,000 autopsies (Mracek). Involvement of the heart-muscle and 
brain-vessels is frequently associated with sudden death. 

1. Independent syphilitic pericarditis is unknown; it is invariably 
a complication of myocardial syphilis, occurring over the large vessels 
or anterior surface of the heart, as serofibrinous pericarditis or com- 
plete concretion. Gummatous pericarditis is always combined with 
the serofibrinous form, and sometimes with aneurysms of the coro- 
nary arteries. The symptoms are those of disordered compensation 
or of myocarditis, its invariable associate. 

2. Syphilitic myocarditis is coronary arteritis; foci of interstitial 
involvement occur, as infiltration along the small vessels, which is 
especially marked in congenital syphilis, and which spreads into the 
intermuscular septa. Microscopically, the general picture of myo- 
carditis prevails. It involves the front surface or apex of the left ven- 
tricle or the intermuscular septum. In congenital syphilis it occurs 
in the right more than in the left heart. Resulting changes are cardiac 
hypertrophy, aneurysm of the heart, and Dittrich's true heart stenosis 
(conus stenosis). Gummatous myocarditis seldom occurs alone, and 
is usually observed with a diffuse myocarditis. Only 97 (62 perfectly 
clear) cases of myocardial gummata are recorded (Stockmann, Gold- 
frank). Gummata may attain great dimensions in the interventricular 
septum. The disease is often latent until, in 50 per cent, of the cases, 
sudden death results, wherein it differs from myocarditis of other 
origin. t Most fatalities occur in persons between thirty and forty 
years of age. The heart action may be incompetent or irregular, and 
there may be dyspnoea, asthma, angina pectoris, or cerebral embolism. 
Hydrops is rare. Amyloid of the heart is occasionally associated with 
gummatous myocarditis. Heart rupture is recorded. 

3. Syphilitic endocarditis rarely develops. The nodules on the 
valves rarely retract, as they do in rheumatism, and therefore consecu- 
tive valvular disease is rare. Mural plaques complicate myocardial 
gummata. Endocardial gummata may occur. 

Bloodvessels. — Endarteritis Syphilitica. — (a) In the fibrous form, 
the wall is thick, and opaque, and the intima and elastic tissue are 
hyperplastic, and the lumen is eccentric. When the muscular coat 
is not involved, thromboses occur; when both the muscular and 
elastic coats are diseased, aneurysms result; this type is known as 
the obliterating endarteritis of Heubner (see Syphilis of the Brain). 



27^ TEE SPECIFIC INFECTIONS 

(b) Guramatous arteritis or periarteritis, occurring with Form a is 
very rare, c) General arteriosclerosis involves the vessels more widely 
than does the syphilitic arteritis which is largely localized in the aorta 
and brain-vessels and exceptionally in the other vessels. Coronary 
involvement is held by some writers to be more frequent than brain 
involvement. It may begin in the first year after infection. 

Aorta. — Syphilitic aortitis Heiberg, 1S77; is oftenest seen in the 
ascending aorta and its arch and thoracic segment. It begins in the 
adventitia or intima and ultimately involves all the walls, though in 
varying degrees. The early stages show gray, transparent, gelatinous 
patches of productive inflammation in the intima; older foci are gray- 
white, round or oval, elevated and stellate plaques. The process 
sometimes becomes deep and calcification occurs in the intima with 
thrombosis. It may extend down into the aortic valves. Its origin 
may be a ■ in the intima. b in the adventitia and media together, or 
[C in the intima and adventitia. The resulting loss of elasticity and 
resistance promotes aneurysm. Welch held that 50 per cent, of aneur- 
ysms were syphilitic: personally, the author believes SO to 90 per cent, 
is a more accurate estimation. Syphilitic aneurysms develop more 
rapidly than those due to other causes. They may be single or multiple 
and usually occur in the arch of the aorta, and sometimes also in the 
abdominal aorta or its branches see Axeeeysm -. Straub found this 
aortitis in 9S per cent, of cases of paretic dementia, and Chiari in 50 
per cent, of syphilities. Benda describes gummata of which only six 
cases are on record . 

Pulmonary Artery. — Valvular gumma is very rare, as are occlu- 
sions of the pulmonary trunk, or its compression by scars. According 
to Neumann, syphilitic dilatation or aneurysm of the pulmonary artery 
has not yet been observed. 

Vein Syphilis. — Thirty-three cases of phlebitis were collected by 
Roussy in 1903. Schuppel has described a periphlebitis originating 
in the adventitia and seen especially in hereditary syphilis. Gummata 
sometimes exist in the veins or involve them secondarily. 

(I). Respiratory Tract. — Nose. — 1. An initial nasal lesion js most 
rare, only 95 cases being recorded. 

2. Acute rhinitis is much rarer in adults than in the new-born 
but is often not recognized. It is characterized by being less diffuse 
than an ordinary rhinitis, by its persistence, by erythematous and 
papular foci, by hemorrhagic erosions with persistent bleeding, by 
fetor, sometimes by acute sinus inflammation, and by hyperplastic 
rhinitis. 

3. Rhinitis atrophicans in syphilis is the result of hyperplastic 
rhinitis. 

4. Gummata usually develop late, though they have been seen in 
the seventh month Mauriac : they occur on the floor and septum of 
the nose, and also in the periosteum, bone, and secondarily in the 
cartilage. They occur with diffuse necrosis or with circumscribed 
gummata in the skin, and involve the cartilaginous and membranous 



ACQUIRED SYPHILIS 279 

septum and cartilages of the alse; sequestra may be blown from the 
nose. Septal perforation may develop and a long course is usual, 
with discharge of pus and crusts; the bone is often denuded. The 
deformed "saddle-back" nose is due to loss of the triangular cartilage 
and vomer, and sometimes to simple atrophy. Difficulty in swallow- 
ing, meningitis, or disease of the antrum, are occasional sequences. 
Differentiation from noma, tuberculosis, carcinoma, and the ordinary 
perforating ulcer of Zuckerkandl (beginning as a hemorrhage and due 
to streptococcic and staphylococcic infection) must be considered. 
The diagnosis ex juvantibus is the best test. 

Larnyx. — 1. Catarrhal laryngitis occurs with the eruption, and at 
times is accompanied by swelling of the tonsils and by pharyngitis. The 
larynx is red and swollen, with a diffuse, thin secretion, which is at 
first thready and later purulent. Coughing and hoarseness are com- 
mon. 

2. In papular and submucous laryngitis the papules often ulcerate 
like ordinary catarrhal ulcers and are often associated with diffuse 
infiltration and nodes. The epiglottis is also involved. Deforming 
ulcers are neither so acute nor inflammatory as the non-syphilitic 
variety. Stenosis of the glottis results if ulcers invade the submucous 
tissue. 

3. Gummata of the larynx (2 per cent.) are usually multiple, and 
vary from the miliary size to that of a pigeon's egg, though sometimes 
they are simply a diffuse infiltration. They may soften, ulcerate, and 
produce dysphonia, dysphagia, dyspnoea, hemorrhage, or suffocation. 
They always leave adhesions, stenosis, scars, or deformity. 

Diagnosis. — In cancer the glands are usually, but not always, 
enlarged; the growth is harder than in syphilis; and the microscopic 
examination may be of value, but is often unsatisfactory. Syphilis 
and tuberculosis may occur together. Though the round form of 
syphilitic ulcer is not of absolute diagnostic value, it usually begins 
near the epiglottis, is rounder and larger, and has sharper edges, a 
more reddened border, and a whitish-yellow coating of its deeper 
base, while the tuberculous ulcer is less red, less infiltrated, less deep 
and less insidious in its development. 

4. Perichondritis may affect any cartilage, the involvement usually 
being secondary. The cartilage is discolored and excoriated, and 
may be surrounded by oedema, and there may be submucous necrosis, 
or difficulty in respiration and deglutition. The prognosis is always 
grave. The lower the necrosis develops, the worse is the prognosis, 
for deformity and stenosis occur. Syphilis causes 13 per cent, of cases 
of glottis oedema; tuberculosis, 9 per cent. 

5. Cicatricial stenosis of the larynx, described in the prelaryngo- 
scopic days by Oppolzer and Tiirck, occurs mostly at the true cords, 
usually with adhesions between the cords anteriorly, and sometimes 
leads to absolute occlusion. 

6. Syphilitic vegetations are rare, and histologically resemble other 
vegetations. They are due to irritating secretions; occur in the larynx, 



280 THE SPECIFIC IXFECTIONS 

epiglottis, and anterior parts of the cords; appear sessile or peduncu- 
lated; and cause dysphonia or even suffocation. 

Trachea. — The trachea is irritated (e.g., by secretions from the 
larynx) mostly in its middle third, and next in its lower third. Only 
two instances of condylomata have been recognized. There may be 
chronic inflammation in the submucous tissue. The trachea is red, 
swollen, and sometimes ulcerated and distorted. Tracheal stenosis, 
resulting from healing gummata, is usually angular (Mauriac); is 
rarely diaphragmatic, and involves mostly the middle third. The 
symptoms are a burning sense of constriction; dyspnoea at night, on 
exertion, or on lying down; a cough resembling that of pertussis, 
with sanguineo-purulent sputum, which may contain fragments of 
cartilage; and cyanosis or lobular pneumonia. The diagnosis may be 
made by the laryngoscope. 

Bronchi. — 1. Acute bronchitis is observed, especially in tubercu- 
lous, cachectic and alcoholic subjects, and was held by Stokes to be 
an enanthem. It is frequent with the secondary symptoms but may 
last months. 

2. Chronic bronchitis often accompanies laryngeal, tracheal, or 
bronchial affections. When there is much secretion, bronchiolitis or 
pneumonia may result with signs resembling phthisis. The breathing 
is disproportionately disturbed (Morton), which is caused by irri- 
tation of the vagus from enlargement of the bronchial glands; dys- 
pnoea, fever, pain, and a thin, green, nummular, sometimes bloody, 
sputum, may be noted. 

3. Kidney-shaped ulcers may cause stenosis and sometimes per- 
foration into the pulmonary artery, mediastinum, or oesophagus. L. 
A. Conner, of New York, collected 128 cases of bronchial and tracheal 
syphilis; in 56 per cent, the trachea alone was affected. 

Luxgs. — Syphilis of the lungs, as first recognized by Morton (eigh- 
teenth century), may cause symptoms like those of pulmonary tuber- 
culosis, and, according to Sims, every case with tuberculous signs 
should be searched for syphilis. 

1. The white pneumonia of hereditary syphilis may be described 
here although it presents no clinical symptoms. The lung is firm, 
heavy, airless, and grayish-white. This condition was called white 
hepatization by Yirchow, the chief change being in the thickened and 
infiltrated alveolar walls. In the air cells, desquamation and swollen 
epithelium are found, with scattered miliary foci about the arteries. 

2. Diffuse infiltration differs from tuberculosis in that it occurs in the 
centre of the lung, on one or on both sides, and exceptionally in the apex 
(Fournier). It usually travels downward rather than upward. In the 
beginning the lung is red, hard, large, airless, and smooth on section, 
and later becomes gray, uneven, and nodulated; the alveoli are filled 
with fibrin, epithelium, and blood-cells. Infiltration of the connective 
tissue occurs, particularly about the vessels impinging upon the air- 
cells. The bronchi are thick, narrowed by connective tissue, or else 
dilated. The origin of this infiltration is disputed. It occurs either 



ACQUIRED SYPHILIS 281 

from desquamative pneumonia, from the alveolar connective tissue, 
from the bloodvessels, from the peribronchial connective tissue, or 
from the lymph-vessels. Necrosis, fatty change, and caseation, may 
result from occlusion of the vessels, which later may result in the forma- 
tion of cavities or pneumothorax. Disproportionate dyspnoea is pres- 
ent. Temperature may occur with or without ulceration. 

3. Gummatous pneumonia may occur alone or with diffuse infiltra- 
tion. Gummata may be found everywhere, but largely in the lower 
lobes near the hilum, whence they spread to the pleura (dry pleurisy). 
Differentiation from tuberculosis is often difficult; the two lesions may 
occur together. Dulness and other signs of consolidation or cavity 
formation often result. The sputum is mucous, purulent, profuse, 
bloody, stinking, and contains masses of tissue but no tubercle bacilli. 
The course is usually chronic, and advanced cases may heal with 
appropriate treatment. Diagnosis is most difficult if the foci are small. 
Tuberculosis occurs more often on the left, and syphilis on the right 
side. Tuberculosis occurs more frequently in the upper, syphilis more 
often in the lower or middle lobes. The history alone may be mis- 
leading. Rise of temperature is more frequent in tuberculosis. In 
syphilis, hemorrhage is rare, as the vessels are obliterated, and night 
sweats are infrequent. In caseous tuberculous pneumonia, localiza- 
tion is of no diagnostic value. 

4. Syphilitic interstitial pneumonia rarely occurs alone, but usually 
with the above affections. The lung may be lobulated like the lobu- 
lated liver, and adhesions may occur at the base; there is marked 
induration in the middle portions of the lung, as irregular branching 
bands, which dilate or distort the bronchi; diagnosis is impossible. 

5. Syphilitic disease of the pleura is rare. It may occur with lesions 
of the lung alone or with pleural gummata. 

(J). Nervous System. — The changes are partly toxsemic, partly ana- 
tomical. Syphilis of the nervous system occurs in men more frequently 
than in women (8 to 1), mostly between the ages of twenty-five and 
forty, in neuropathic subjects, and after trauma; in brain workers or 
those debilitated by worry, excesses, or from lead or nicotine; and in 
cases of acquired syphilis, or in children as perhaps the first symptom 
of parental disease. 

The primary lesion often escapes recognition. In 20 per cent, of 
cases, there is no history of chancre. It occurs where the secondaries 
have been light and have had ineffectual or no treatment. Syphilis 
is said to occur in the brain in 16.5 per cent, of syphilitics, more, in- 
deed, than in other viscera, excepting the liver. (Again, it has been 
held that only 10 to 15 per cent, of syphilitics have visceral, and only 
3 per cent, brain, complications.) 

Fifty per cent, of brain syphilis occurs within three years after infec- 
tion. Formerly described as occurring many years after infection, 
instances are recorded where cerebrospinal syphilis developed even as 
early as five weeks after infection. Nervous symptoms may occur soon 
after an infection in those advanced in years (Kuh). Early nervous 



282 THE SPECIFIC IXFECTIOXS 

symptoms, as headache, neuralgia, spinal pain, increased reflexes, or 
fleeting paralyses, may occur in the secondary stage and are probably 
chiefly toxsemic. 

In general, the symptoms are marked by — (a) variability, undulation, 
inconsistency and inconstancy, due to the characteristic growths and 
vessel changes which regress and recur; (b) incompleteness, as partial 
paralysis or partial disturbance of consciousness; (c) the symptoms 
are partly tumor-like, partly vascular, or partly inflammatory ; they are 
partly meningeal, partly basal or cortical, and rarely occur in the centre 
of the brain except from secondary vessel lesions and gummata. The 
disease may begin with diffuse neurasthenic, meningeal, psychopathic 
or focal symptoms. As TYunderlich stated, syphilis produces no 
symptom not produced by other disease; therefore, no typical picture 
obtains. 

Types. — 1. Basal gummatous meningitis, the most studied type, 
and, after arterial disease, the most frequent form, begins in the dura, 
especially along the chiasma opticum, in the interpeduncular spaces, or 
along the cavernous sinus; less frequently in the fossa of Sylvius and 
the cortex; pathologically it consists of fibrinous exudate, granula- 
tion tissue, cicatrices and gummata. 

General Symptoms. — Headache (in 66 to 75 per cent, of the cases) 
is the most important, constant, and early symptom. It is paroxysmal, 
or, if persistent, is increased at night, is sharp, boring or dull, is super- 
ficial, or deep-seated (Fournier) and but rarely circumscribed. Other 
symptoms are neuralgias, cerebral (projectile) vomiting, vertigo, and 
changes in mentality (somnolence, semi-intoxication, or impulsive, 
motiveless activity and loss of the aesthetic sense). Again, the brain 
may be normal, except during the attacks, — e. g., coma may occur 
from which spontaneous recovery is possible. Persistent sleep has 
been observed, lasting for weeks or months and is usually ominous. 
The brain activity may be tardy or excited, while nocturnal automa- 
tism (Wood) or dementia, may develop, alternating with delirium, epi- 
leptic attacks, or paralytic seizures. The brain symptoms may, on 
rare occasions, resemble those of uraemia, meningitis or typhoid. Epi- 
lepsy may be typical or unilateral, frequent or violent; tetanic or 
cataleptic seizures may occur. Polyuria or polydipsia (33 per cent, of 
cases), diabetes insipidus (probably resulting from disease in the third 
ventricle), or diabetes mellitus (of which Oppenheim has collected 20 
cases) may occur. Fever may be present; it is irregular, and usually 
accompanies the secondary manifestations. 

The cerebral nerves are often affected, especially the second and third. 
Involvement of the nerve trunks or branches successively is most 
characteristic (85 per cent., Uhthoff); 80 to 90 per cent, of cases of 
nerve involvement results from syphilis of the brain, tabes, or less fre- 
quently, from general paralysis and brain tumor, (a) The third nerve 
is involved most frequently — 50 to 80 per cent, of the cases, "the sign 
of syphilis" (Ricord). (b) Disease of the optic nerve occurs anatomic- 
ally in 82 per cent, and clinically in 40 per cent, of cases. Choked 



ACQUIRED SYPHILIS 283 

disk (10 per cent.) is almost always bilateral. (See Retinal Plates 
under Miliary Tuberculosis.) Neuritis is unilateral in 4.6 per 
cent.; simple atrophy, with complete blindness (in 6.6 per cent.), is 
most frequent in tabes and next most frequent in brain syphilis and 
general paralysis. Involvement of the opticus rarely occurs as an 
independent syphilitic lesion. Amaurosis is common and often uni- 
lateral. Hemianopsia is homonymous. Temporal heteronymous hemi- 
anopsia is very often syphilitic while the nasal form is rarely so. In 
5 per cent, of cases the field of vision is constricted. The eye changes, 
due to meningitis, bone disease, or gumma, are susceptible to treat- 
ment, (c) The fourth nerve, (d) the sixth, and (e) the fifth nerve are 
next in frequency of involvement. The fifth is unilaterally affected, 
and more in its sensory than in its motor branches. The olfactory 
nerve is rarely involved. The facial nerve may be paralyzed, nearly 
always unilaterally and peripherally. The eighth nerve is sometimes 
involved, and the Meniere symptom-complex results, which, accord- 
ing to Fournier, is ominous. The lower nerves, such as the vagus, or 
hypoglossus, may be affected. Together with the above changes 
gummata may grow into the pons, crus, or medulla, and may cause 
hemiplegia and crossed paralyses, as hemiplegia plus oculomotor 
paralysis (Weber's paralysis) ; plus facial paralysis (Gubler's paralysis) 
or plus abducens and trigeminus paralysis (Ley den's paralysis). In 
basal meningitis, arterial phenomena are often noted; in the cortical 
region they are evidenced by syncope or apoplectiform attacks from 
sudden variation in the blood pressure; toward the base (central 
ganglia) they produce encephalomalacia, hemiplegia, hemianesthesia, 
and hemianopsia. These, however, are usually later symptoms than 
meningitis and neuritis. The course of syphilitic meningitis is rarely 
acute or chronic, the typical type being subacute with remissions and 
exacerbations, and lasts rarely more than a half a year, unless treat- 
ment has been given. Headache, convulsions, sopor, coma, delirium 
and neuritis are followed by irritative and paralytic symptoms with 
remissions, then with renewal of older, or advent of new, symptoms. 

Differential Diagnosis. — Carcinoma and sarcoma at the base of the 
brain, which involve the meninges, run a continuous progressive course, 
with definite localization and with few changes in the vessels, while 
in syphilis the course is intermittent or remittent, localization varies 
and changes in the vessels may be marked. Tuberculous meningitis 
may exceptionally give identical symptoms, but there is less develop- 
ment of connective tissue, vascular changes are rarer, the nerves less 
frequently involved, the course more acute, febrile, and progressive, 
and remissions less frequent and less marked; stiff neck and general 
muscular rigidity occur, which are rare except in the congenital type 
of syphilis. Mental obscurity is more marked and sudden, while it 
intermits in syphilis. The irritation, in the initial stage, is followed 
by paralysis later, while paralysis may occur at once in syphilis. 
Tuberculous meningitis is a disease of the first, second or third decen- 
nium, while svphilis usually occurs after twentv years of ao-e. Other 



284 THE SPECIFIC INFECTIONS 

syphilitic or tuberculous foci and the results of therapy determine the 
differentiation. The two affections rarely co-exist. Differentiation 
from Quincke's serous meningitis may be difficult, but the variations 
in the syphilitic variety and the results of the therapy are the final 
tests. Differentiation must be made from primary syphilitic neuritis 
and from multiple syphilitic root neuritis. It is questionable whether 
primary involvement of the second and third nerves may occur in 
syphilis. It is rare at the base of the brain and these cases are generally 
caused by an anatomical meningitis with but few symptoms. The 
multiple nerve root affections of Kahler, involving the seventh and 
third cerebral and the cervical and dorsal nerve roots, were observed 
without symptoms of meningitis or tumor, and caused neuralgia, and 
paralysis. Optic neuritis requires differentiation from similar changes 
due to tumor, alcohol, nephritis, diabetes and acute infections. 
Periodic paralysis of the third nerve is rhythmic in its attacks, usually 
involves the entire nerve, occurs in young children especially, and with 
attacks of migraine. 

2. Syphilis of the convexity may occur as circumscript or diffuse 
meningitis or meningo-encephalitis, with symptoms like those of cor- 
tical tumor or with diffuse manifestations. 

General Symptoms. — Headache is usually the first and most com- 
mon, though convulsions may be the first, manifestation. Mental 
symptoms may occur independently of the localization. Focal symp- 
toms are the Jacksonian attacks or epilepsy, which occurs with mono- 
or hemiplegia, sometimes with local tenderness, develops by starts or 
" installments" and occurs without an aura. Ninety per cent, of con- 
vulsions occurring in those over thirty years of age, not ursemic or 
alcoholic, are syphilitic (Fournier). The symptoms are more diffuse 
than in vulgar epilepsy. The convulsions may even number 400 in 
twenty-four hours. Pain, or paresthesia occur, but anaesthesia is 
uncommon. Aphasia is frequent and is usually of the transitory motor 
type at first, word deafness being relatively rare; aphasia occurs less 
often from gumma than from vascular disease. Alexia and agraphia 
have been observed. When the process is diffuse it may be manifested 
clinically as an acute psychosis which can be cured only with anti- 
syphilitic therapy; dementia is the most frequent type. Both the 
diffuse and gummatous forms recover more frequently than do other 
forms. 

3. Syphilitic arterial disease occurs alone or with the other varie- 
ties of brain syphilis. It is the most frequent form and (aside from 
paralysis of the nerves), is the most frequent cause of syphilitic par- 
alysis. There are prodromal disturbances; headache is usual but less 
constant than in meningeal syphilis; vomiting, vertigo, dulness, psy- 
chical changes, dementia, convulsions, intermittent hemianopsia, and 
aphasia may occur; choked disk is rare; thrombosis and obliteration 
of the vessels is gradual in onset and is intermittent, — e.g., it may 
involve the leg and, in a few hours or days, the arm. These changes 
are due to obliteration of the vessels and multiple softening which 



ACQUIRED SYPHILIS 285 

(in 95 per cent, of cases) occurs in the Arteria Fossae Sylyii; pseudo- 
bulbar paralysis may rarely result from involvement of the bulbar 
vessels. 

Course. — The first attacks are mild and short; the later ones are 
more severe, and occur with marked somnolence, very frequently with 
bilateral, alternating, or crossed paralysis, with general or unilateral 
convulsions, which are rarely Jacksonian in character, or with partial 
or mixed aphasia, mental changes, and progressive bulbar phenom- 
ena, such as dysphagia. They result from arterial disease or hemor- 
rhage, the latter of which is most rare except from rupture of a cerebral 
aneurysm. 

It may be difficult to diagnosticate primary syphilitic disease from 
the ordinary arteriosclerosis; the latter in over 90 per cent, of cases 
occurs in late life, its progress is slower, the changes are more dis- 
seminated, all coats of the vessels are involved, the more frequent 
fatty and calcareous changes lead more often to widening than to 
obliteration, psychical changes and convulsions are less frequent and 
hemorrhage is more characteristic than softening; whereas in syphilis, 
encephalomalacia occurs at a younger age (See Brain Embolism, Dif- 
ferential Table), the changes chiefly affect the aorta and brain vessels, 
the intima is chiefly involved (the entire artery and tissue about the 
artery are exceptionally implicated), calcareous and fatty changes are 
rare and obliteration is usual. Syphilitic endarteritis is more acute in 
development and the headache is more severe and is nocturnal. There 
are such characteristic psychical changes as somnolence or apathy; 
the hemiplegia occurs by "epochs" or "installments," is associated 
with meningitis, dementia, or delirium; finally the symptoms are more 
diffuse than in senile arteriosclerosis. Syphilitic endarteritis some- 
times occurs without softening. This type may occur with spinal 
syphilis or may produce the pseudo-apoplectic attacks, in tabes (Minor, 
Kuh, Heubner, Dinkier). Without treatment, the average duration 
is one to three months (Oppenheim). 

Dieulafoy has carefully described aneurysms in the basilar, the 
Sylvian, and carotid trunks; they are not necessarily tertiary but may 
occur eight months after infection. Their rupture produces symptoms 
of apoplexy or meningeal hemorrhage. Otherwise hemorrhage is rare 
in brain syphilis. They are often multiple. (See illustrations under 
Aneurysm.) 

While softening is usually ischsemic and not inflammatory, we some- 
times encounter foci of encephalitis syphilitica as (a) disseminated 
foci in the brain and cord; (6) indurated sclerosis; (c) softening 
occurring apart from disease of the vessels, and very rarely observed 
in secondary syphilis. 

4. Gummata are the least frequent variety; they may occur in any 
part of the brain, usually in the meninges, although sometimes in the 
medullary substance, central ganglia, cerebellum, pons or cms. If 
they occur alone the symptoms are the same as in brain tumor, except 
that there is often regression, which is either spontaneous or results 



286 THE SPECIFIC INFECTIONS 

from antisyphilitic treatment. Cortical gummata, producing cortical 
epilepsy and monoplegia, require differentiation from other tumors 
as tubercle or glioma; in cortical tumor the headache is duller and 
deeper; the pressure symptoms, mental depression, and slow pulse are 
more marked; the disk changes follow focal symptoms and the process 
advances less by epochs; while in syphilis the headache is frequently 
local and the pressure symptoms are more diffuse, being those of more 
rapid extensive involvement; the disk, as a rule, is involved only when 
coincident basal meningitis occurs. Cortical paralysis may develop, 
and is often associated with Jacksonian epilepsy (v.s.). The symp- 
toms are -more undulatory, and finally success in treatment is per- 
manent (though slight temporary improvement may follow antisyphilitic 
treatment in cases of genuine tumors). 

5. Cerebrospinal syphilis produces no characteristic spinal symp- 
toms; suggestive, however, are (a) their asymmetry, (J>) their less pro- 
nounced character, (c) their variability, (d) meningeal and nerve root 
symptoms, and (e) response to mercury and iodides. Syphilis is never 
a system-disease (Gowers). Syphilis of the cord is five to six times 
less frequent than brain syphilis. 

The most frequent and characteristic form is cerebrospinal men- 
ingo-encephalitis, which is observed in both acquired and congenital 
syphilis. While the symptoms may be strictly spinal (spastic spinal 
paralysis, myelitis and meningitis), anatomical brain changes, such as 
gummatous meningitis or meningo-encephalitis are frequently found. 
Of the three sets of spinal bloodvessels, the peripheral are most in- 
volved and Heubner's findings (considered by some characteristic of 
arterial brain syphilis), are not noted in them. Brain changes usually 
occur first and may conceal the spinal symptoms, so that doubt often 
exists whether some symptoms are spinal or cerebral. The meninges 
are most involved in the cervical and upper dorsal region, as evi- 
denced by pain, stiffness, or girdle sensation; while the cord itself is 
mostly affected in the lower dorsal region, and therefore involves 
chiefly the lower extremities, and causes weakness in the legs, par- 
esthesia, sphincter disturbance, and decubitus. Intercostal neuralgia, 
pains in the extremities (often most severe at night), spastic parapar- 
esis, hemiparaplegia, triplegia, Brown-Sequard's syndrome, anterior 
poliomyelitis or amyotrophic lateral sclerosis, increased (varying) 
reflexes, involvement of the bladder and rectum, and general or selec- 
tive sensory disturbances, are some of the symptoms of cerebrospinal 
syphilis. Erb has laid special stress on the spastic paraplegic type. 

Varieties.— (a) Gummata of the bones. These are exceptional, as 
are also exostoses and caries. 

(b) Gummatous meningitis. This is most frequent, and includes 
pachymeningitis (see p. hypertrophica cervicalis of Charcot). 

(c) Meningo-myelitis. This is myelitis secondary to meningitis, 
with connective tissue and vascular changes. It is now maintained 
that the so-called syphilitic myelitis is only softening — i. e., myelomal- 
acia. 



ACQUIRED SYPHILIS 287 

(d) Gummata of the cord. These are relatively infrequent. 

(e) Vascular disease. Softening is rare and involves small areas 
only. 

(/) Perineuritis gummosa of the sensory or motor nerve roots. 

Differentiation from combined system-disease is often difficult. 
Some cases of ascending paralysis are considered syphilitic, and some 
have certainly been helped by mercury. In cerebrospinal syphilis and 
parasyphilitic tabes or dementia, the lymphocytes predominate in the 
fluid withdrawn by lumbar puncture. 

Steady progression and constancy of symptoms characterize mul- 
tiple sarcomatosis of the brain and cord. 

Prognosis of Brain Syphilis. — According to Naunyn, only 48 per 
cent, of the cases recover. The later the disease, the worse is the 
prognosis. The prognosis is more favorable in meningeal (i. e., extra- 
cerebral) involvement, when nerve symptoms are dominant, when 
epilepsy and other symptoms of peripheral brain irritation occur, or 
when early treatment is instituted. The prognosis is less favorable in 
specific arterial disease (paralysis from softening), in bulbar forms, in 
diffuse involvement, in great psychical alteration, and in proportion 
as the primary and secondary lesions were poorly developed; also in 
extragenital infections, in hereditary syphilis, and in complicating 
trauma, tuberculosis or alcoholism. Eighty-two to 88 per cent, of 
cases of syphilis receive insufficient mercurialization (Hjelman). 
Recovery is rarely complete and recurrence may be observed. The 
prognosis is relatively poor in spinal lesions. 

6. Syphilis of the peripheral nerves may cause facial and 
trigeminal paralysis, even in the secondary stage. The most frequently 
affected spinal nerves are the occipital and auriculotemporal. Other 
nerves are infrequently involved, as the crural or popliteal. Peri- 
pheral (multiple) neuritis is rare, yet isolated perineuritis and neuritis 
gummosa (nodosa) are recorded. 

(K). Eye and Ear. — Syphilis comprises 2 to 3 per cent, of all eye 
diseases and at least 3 per cent, of all syphilitics have eye disease. Any 
part may be involved, except the lens, which suffers only from arterial 
disease in the uveal tract. The uveal tract is most involved; next in 
frequency come the retina, optic nerve and eye-muscles. Suppuration 
or inflammation may occur in the lachrymal duct; the gland is prac- 
tically immune. The lids are not often involved; chancre, condyloma, 
and gumma, may occur, and are easily confused with chalazion. 

Conjunctiva. — Twenty-two scleroses (Guzeit) have been observed, 
as well as a few gummata; catarrh occurs usually in the secondary 
stage. 

Cornea. — The cornea is frequently involved: (a) as parenchy- 
matous keratitis, which is mostly observed in congenital syphilis, and 
occurs even in the third generation, while in acquired syphilis it occurs 
in but 2 per cent, of cases. " Hutchinson's triad " in congenital syphilis 
consists of keratitis, notched teeth, and congenital or early acquired 
deafness. The cornea is diffusely clouded and milky, and on close 



288 THE SPECIFIC IXFECTIOXS 

examination shows patches or streaks of inflammation and sometimes 
new-formed vessels; (b) as keratitis parenchyniatosa,the circumscribed 
or the punctate variety; (c) as gururaa, which is infrequent; (d) as 
keratoinalacia, which is observed in the congenital variety. The sclera 
is involved secondarily to disease in adjacent parts. 

Iris. — Of all inflammations of the iris, 23 per cent. (Cohn) to 75 
per cent. (Mauthner) or 90 per cent. (Klein) are syphilitic. The 
symptoms are those of other varieties of iritis — ciliary injection with 
discoloration, narrowed pupil, slow reaction, and synechia or occlu- 
sion of the pupil. It is usually plastic, or exudative with tiny papules 
(Fuchs), and is rarely purulent; gummatous iritis with nodules, if it 
is not the result of trauma, is strongly indicative of syphilis (in 12 to 
30 per cent, of such cases, Klein). Iritis is usually secondary and 
rarely tertiary, or if so, it occurs in foci of an old iritis. Without cyclitis 
it is rare in congenital syphilis. As it rarely heals completely, atropine 
should be administered early while mercury is being given, for expec- 
tant treatment results in severe lesions and inflammation tends to 
recur. Serous iritis may occur in the form of fine brown spots on the 
posterior surface of the cornea. They are often triangular in arrange- 
ment, with injection, disturbance of sight, and a few synechia?. Ciliary 
involvement is usually secondary, rarely tertiary and may be the sole 
symptom of syphilis. Injection and exquisite tenderness to touch are 
characteristic. Because of their intimate vascular connection, cyclitis 
is often associated with iritis. Gummata usually heal; recurrence is 
not infrequent. 

The Choroid is involved late in the secondary period; it may be 
involved secondarily to iritis or cyclitis. There are several forms but 
all terminate with much the same appearances — e.g., the exudative 
choroiditis with bright yellowish, bluish, or even rose-colored spots, 
which are small, oval, or irregular, and are usually peripherally 
pigmented. The pigmented type is without spots. Both the spots 
and pigment lie behind the retinal vessels, which branch over them in 
the ophthalmoscopic picture. (See Retinal Plates under Miliary 
Tuberculosis.) Disseminated choroiditis consists of spots of pig- 
ment, especially in the peripheral eye ground, and is usually an indica- 
tion of syphilis. Choroiditis may occur suddenly, with great pain and 
reduction in the tension of the eye, and with synechia? and disturbed 
vision. When occurring with inflammation of the retina and choroid 
(choroiditis totalis) the prognosis is usually bad, as blindness may result 
from recurrent attacks. Though no objective signs positively point 
to a syphilitic origin, syphilis is always suspected. The vitreous humor 
is frequently involved after other lesions, especially those of the uvea, 
and is rarely involved alone. As it usually occurs late, it results merely 
in opacities or dust -like bodies; in the absence of myopia and hemor- 
rhage, it rattier indicates syphilis. 

The Retixa is involved chiefly in its anterior layers, becoming 
cloudy about the disk, with opacity of the nerve and blurring of the 
disk outlines. The course of the arteries is lost or broken and the 



ACQUIRED SYPHILIS 289 

veins are tortuous and engorged. Hemorrhages are not common. 
Most idiopathic cases of retinitis are syphilitic, although no unique 
morphological characters exist. Nodules, either papules or gummata, 
constitute the specific retinitis. This is usually late or tertiary and 
its prognosis is usually good. Central recurring retinitis (v. Graefe), 
commencing at the macula, is of great importance. Retinitis with 
pigment formation occurs mostly in congenital syphilis. The optic 
nerve is usually involved with the retina. It may be involved any- 
where from its central origin to the disk. It is involved less fre- 
quently than is the uveal tract. So-called rheumatic neuritis is often 
syphilitic. Sometimes the change is simple blue atrophy; again the 
appearance is nearly normal, or again choked disk occurs. The 
causative lesions are gumma in the brain, basal disease or independent 
syphilitic inflammation of the intracranial portion of the tract. Neither 
its syphilitic nature nor its location can be diagnosticated by the oph- 
thalmoscope. The nerve alone may be involved — e. g., atrophy may 
occur, as it does in tabes or progressive paralysis. Amblyopia or amau- 
rosis may result from transitory, circulatory, or permanent, organic 
changes. Hemianopsia is often central, results from lesion in the 
optic tract, and, in most cases, is transitory. 

The Eye Muscles are involved as frequently as is the iris. Syph- 
ilis is a more common cause than is usually recognized, explaining 
many so-called rheumatic cases. More than half the paralyses of the 
eye muscles are syphilitic. Ocular paralyses may be (a) peripheral; 
(b) intracranial as at the base of the brain; or (c) central, comprising 
nuclear, fasicular and cortical localization. Anatomically the following 
lesions occur: diffuse syphilitic basal meningitis, basal gummata and 
periostitis, cellulitis of the orbit, diffuse arterial disease of Huebner, 
nuclear disease, poliencephalitis, gummata of the hemispheres or cor- 
tex, and rarely hemorrhage. Other causes, as tabes, general paralysis, 
tumor, tuberculosis and cancer must be considered. Thirty-six to 50 
per cent, of nuclear paralyses are syphilitic. According to Gowers, 
syphilis frequently produces progressive paralysis of all the muscles 
of both eyes. The oculomotor is involved in at least 65 per cent, of the 
cases (Alexander, Uhthoff). Total paralysis is rare; if it occurs, the 
lesion is usually at the base, is rarely orbital, or may be nuclear with 
localization in the third ventricle, especially if one twig after another 
become involved. If it is partial, it is usually nuclear, rarely neural or 
muscular. Ptosis occurs very frequently, and is highly suggestive of 
syphilis. Abducens and trochlear paralysis may occur. Ophthalmo- 
plegia interna, involving the sphincter iridis and the ciliary muscle, 
produces mydriasis and paresis of accommodation, and is sometimes 
an unfavorable symptom. Thirty-six per cent, of all mydriases are 
syphilitic (Alexander). Its origin is purely nuclear (Mauthner). 
Ophthalmoplegia externa may occur with facial paralysis, involving 
the orbicularis palpebrarum, or with trigeminal paralysis involving the 
sensory filaments of the eye (in 25 per cent, of cases of brain syphilis, 
Uhthoff). 

19 



290 THE SPECIFIC INFECTIONS 

Orbit. — Cellulitis and periostitis occur frequently. Periostitis is 
indicated by deep pain on pressure over the eyeball, or over the edge 
of the orbit, which is sometimes prominent; by pain on movement 
of the eye; more rarely by blindness, exophthalmos, and thrombosis. 
Periosteal gummata may often be mistaken for tumors. 

Ear.— Four instances of primary sclerosis on the external ear have 
been noted (Politzer). The ear in general is involved in 0.6 per cent, 
in acquired syphilis; 33 per cent, of children with hereditary syphilis 
are deaf. Secondary eruptions, as maculse or condylomata, mastoid 
periostitis or gumma, sclerosis or gumma of the Eustachian tube, sup- 
purative otitis media, sclerosing otitis media and labyrinthine disease 
(rapid deafness, vertigo, and tinnitus), may be observed. 

(L). Gentalia. — Some primary lesions occur in the urethra. Secon- 
dary manifestations are infrequent, though gummata have been oc- 
casionally observed in the urethra and bladder. 

Penis. — Gummata may occur at the site of the primary lesion or 
elsewhere, and have often been confused with the primary ulcer, 
chancroids, pustules, or carcinoma. 

Testes. — (a) The diffuse interstitial form (orchitis fibrosa syph- 
ilitica) occurs with great enlargement; the swelling is oval or pyri- 
form, with flattening of the epididymis; it is more often nodular than 
smooth, and is due to periorchitis (the albuginitis syphilitica of Ricord), 
or sometimes to gummata. Serous effusion and partial or total syne- 
chia occur. Recovery by absorption of this sarcocele syphilitica may 
result. Some changes may occur in the epididymis or spermatic cord. 
The connective tissue is increased and the canals are compressed, 
separated, sparse, fatty, pigmented, and infiltrated with round cells. 
(b) Gummatous orchitis is less frequent, and usually involves one testis, 
and also the epididymis and cord, more than the first form. Great 
swelling may occur, may be symmetrical or irregular, and frequently 
involves the entire organ, which is elastic, firm, and studded with 
miliary or giant gummata, has thick bloodvessels, and shows per- 
foration with fungus-like granulations, or suppuration. It is often 
mistaken for sarcoma. The testes atrophy and sclerose. The symp- 
toms begin gradually, or develop after strain or trauma. The 
anterior portion of the testis is most involved, with single or multiple, 
hard, irregular nodules, which are usually not painful. The veins are 
dilated and adhesions occur. The scrotum is infiltrated and nodular, 
and red or violet in color. Perforation is frequent, with a crater-like 
opening and irregular edges. Oligospermia, azoospermia or impoten- 
tia may occur, though this is not always the case, because islets of 
functionating tissue frequently remain. Differentiation is required 
from gonorrhceal orchitis, which is more rapid, painful, and which in- 
volves the epididymis first. Plastic orchitis, resulting from stricture, 
traumatic orchitis, and mumps orchitis, must be considered; also tuber- 
culous disease, which is often bilateral, or which at least occurs in 
several foci, and frequently involves the cord, vesicles, epididymis and 
often causes perforation with pain, fever, and prostration, in which 






ACQUIRED SYPHILIS 291 

case tubercle bacilli may be detected. Differentiation is also necessary 
from sarcoma, which is harder, develops more rapidly, is more nodular, 
produces lancinating pains, and frequently affects the epididymis and 
cord, which are less often involved in syphilis. Sarcoma also invades 
the glands, and, when perforation results, is more rapid and painful, 
and occurs with fever, necrosis, hemorrhage, and cachexia. Car- 
cinoma, which is often difficult to differentiate from the interstitial 
form of syphilis, does not respond to specific treatment. 

Vas Deferens.— This is rarely involved, and is seldom affected 
alone, though gummata may form. Syphilis of the seminal vesicles 
may convey the disease to the mother and child. Prostatic involve- 
ment is rare. 

Vagina. — In the vagina, primary infections are relatively rare, be- 
cause of its thick epithelium and the paucity of glands; secondary 
eruptions are rarely observed. Condylomata occur which may be con- 
fused with colpitis granulosa. They must disappear under mercury 
to make certain the diagnosis. Gummata rarely occur alone and sel- 
dom affect the whole circumference. 

Vulva. — The vulva is very frequently the seat of secondary lesions, 
upon which tertiary lesions develop from microscopic residua of secon- 
dary eruptions. These may extend to the urethra or bladder. Enor- 
mous swelling, sometimes resembling blisters, is a common result of 
lymphatic involvement. Phagedenic ulcerations or strictures may 
occur. Gummata are readily differentiated from carcinoma and 
tuberculosis. 

Cervix. — Chancre occurs in 5J per cent, of the cases (Fournier, 
Mracek and Neumann). Scars may result with stenosis, and sterility. 
Chancre in this location is promoted by erosions and by a low posi- 
tion of the uterus. Tertiary lesions may occur and recur. Diagnosis 
may be difficult. 

Syphilitic endometritis is frequent; its symptoms are the same as 
those of the non-syphilitic type. Previous endometritis may be in- 
creased by syphilis; metrorrhagia may respond only to mercury. 
Virchow describes a papular and a tuberous variety. Endometritis 
may produce sterility. Metritis syphilitica has been less studied, but 
some clear cases are recorded, in which large tumors have disappeared 
on administration of iodide. Specific perimetritis or simple perime- 
tritis is secondary to rectal disease, and is frequently located in the 
pouch of Douglas, with gummata, adhesions, dislocations or with 
sterility. 

Effect on Pregnancy. — The ovum may be infected without infection 
of the mother, if abortion occurs in the first two months, before de- 
velopment of the placental circulation. Later the child infects the 
healthy mother in direct ratio to the advance of gestation. The child 
may escape infection, only to become infected later by preexisting or 
post-conceptional syphilis of the mother. Fraentzel has found peri- 
and endarteritis in the placental villi with infarction and necrosis from 
occlusion of the vessels. Thrombosis in the umbilical vessels results 



292 THE SPECIFIC INFECTIONS 

in the death of the child, and in abortion. Adhesions may occur, so 
that only part of the placenta is expelled, and these are, according to 
Neumann, the foci of the specific disease. Miliary gummata have 
been found in the maternal portion of the placenta. 

Tubes and Ovaries. — Salpingitis gummosa has occurred. Oophor- 
itis syphilitica has been described and also gummata, which disappear 
on administration of iodide. 

(M). Bones, Joints, and Muscles. — Secondary periostitis produces 
pain, tenderness, and considerable swelling, which is hard at first, 
and later is elastic even to fluctuation. It occurs especially on parts 
subjected to trauma as on the forehead, temporal bone, sternum, ribs, 
tibia, or clavicle. Osteophytes develop in the cambrium layer, which 
later becomes adherent. Fugitive pain may occur with the secondary 
eruption. The pain of periostitis is fixed; it may radiate but rarely 
migrates, is increased by pressure, is largely boring in character, 
appears at night — the dolor es nocturnce — and disappears at one or 
two o'clock in the morning with sweating, but otherwise resembles 
other varieties of periostitis. In 28 per cent, of cases it occurs in 
the frontal or temporal bones, and forms circumscribed, smooth, 
elastic, and immovable tumors. It may also occur on the ribs, caus- 
ing pain on coughing, neuralgia over the sternum, or possibly 
dyspnoea. Tibial nodes occur in 16 per cent, of cases. Periosteal 
changes last for five or six weeks and are sometimes associated with 
arthritis. Gummata of the bones were the first well-studied form 
of gummata. They occur on the exposed parts largely as : (a) Diffuse 
subperiosteal infiltration, which causes molecular destruction of the 
bone, and possibly reaches the marrow or meninges (perforating type). 
Osteophytes develop, and are the result of an effort of nature toward 
regeneration. The bone may rarefy or show foci of sclerosis; mul- 
tiple areas exist, in the pernicious forms of gummata. In large bones 
sequestra may form, especially in the femur; osteophytes may develop 
in the diaphysis, and sometimes resemble arthritis deformans, (b) 
Circumscribed gummata, the most important form, develop chiefly in 
the periosteum; they form elastic, immobile tumors which are not 
especially tender, and which afterward soften and, at a very late stage, 
may develop connective tissue and calcification. 

Symptoms. — Gummata of the cranium are single or multiple; are 
attended by dull pain, especially at night; have a slow growth; are 
at first soft, and later become hard and have a wall-like, hard edge. 
They rarely ulcerate and often disappear spontaneously, leaving a 
somewhat elevated periphery and a deep centre. They last for a 
month or two, and are very often mistaken for supra orbital 
neuralgia, or migraine. Tuberculous ulcers rarely occur in this 
location. Pyogenic infection may produce ulceration; or menin- 
geal symptoms such as epilepsy, coma, paralysis, or dementia, may 
develop. Gummata may occur at the base, where periostitis is ob- 
served infrequently ; they occur chiefly in the middle fossa and involve 
the nerves or bloodvessels. Diffuse gummatous infiltration develops 



ACQUIRED SYPHILIS 293 

very slowly, with little pain, possibly with ulceration and exposure of 
the bone and is diagnosticated with difficulty. The spine is rarely 
the seat of gunimata; but when it is involved, the affection is largely 
cervical, rarely dorsal, very rarely lumbar, and includes the bodies of 
the vertebrae less than their processes and arches, in contradistinction 
to tuberculosis. Pain and immobility are observed. The head is 
held in the hands, if the atlas is involved; recovery is possible, but 
death may result from ulceration, pressure on the medulla, or lux- 
ation. Paralysis of the upper extremities has been observed. The 
humerus, radius, and carpus, are less frequently involved. The pha- 
langes may be involved, but this usually affects one finger only, the 
spina ventosa, the parts being swollen, but soft, with periosteal 
thickening, shining appearance, and rarely pain or ulceration. The 
clavicle, from its slight protection and its exposure to trauma, is very 
frequently involved; the course is slow, often without pain. Ulcer- 
ation of the sternum is frequent; that of the ileum and sacrum is 
rare. Involvement of the tibia, patella, femur, tarsus, or toes, 
may occur. 

Joints. — (a) Acute synovitis, of recent syphilis, occurs alone or with 
bone changes at the time of the eruption; pain alone may be observed 
or the swelling may be multiple, constituting the pseudorheumatism 
of Fournier, with tenderness, nocturnal pain, immobility, temperature, 
fluctuation and involvement of the periarticular structures, as the 
muscles and tendons. The acute form is polyarticular, while the sub- 
acute variety is oftener monarticular. The knees are most frequently 
involved, and, according to Fournier, more than three joints are never 
affected. The affection may last for weeks or months, does not lead 
to cardiac complications, and responds to mercury and iodide, and 
rarely to salicylates, (b) Chronic synovitis or arthritis is usually 
monarticular, indolent, with little or no pain or fever, and affects 
chiefly the knee and elbow, with slow loss of function and fluctuation. 
It responds to antisyphilitic treatment, (c) Joint disease of late syph- 
ilis originates in the bone or cartilages (tumor albus syphilitique of 
Richet), and affects chiefly the knee and elbow and next in frequency 
the ankle. The central portion of the cartilage is involved, and not 
its edge, as is the case in arthritis deformans. This is probably due 
to gurnmata originating in the bone and is most frequently seen in 
congenital syphilis. The symptoms begin slowly with moderate pain, 
swelling and localized tumors; no temperature is observed, the symp- 
toms vary, and contracture may result. There may be a close resem- 
blance to tuberculous lesions, diagnosis from which depends upon 
other stigmata of syphilis or tuberculosis; while tuberculosis is usually 
inflammatory, incipient syphilitic lesions are non-inflammatory; in 
syphilis, sequestration and ulceration are infrequent; therapy is the 
final test. 

Muscles. — Early involvement may occur, even before the eruption, 
from (a) tox&mia, or (b) myositis. The latter is either a diffuse or 
circumscribed infiltration, which possibly results in muscular contrac- 



294 THE SPECIFIC INFECTIONS 

tures and limited motion, especially in the biceps, arm flexors, finger 
flexors, sphincter ani, masseters, deltoid, and sternocleidomastoid. 
The course is subacute or chronic, depending on treatment. The 
affection is most often observed from two to twelve months after 
infection. Diagnosis from muscular rheumatism may be necessary. 
Gummata of the muscles are important because of confusion with 
neoplasms, especially when they occur in the arms and neck; they 
may be as large as the fist, single or multiple, usually with a firm con- 
nective-tissue capsule; they involve the long muscles, especially at 
their attachments. The course is long, and regression may occur with 
induration. Myositis ossificans is rare. Syphilitic atrophy of the muscles 
may follow arterial disease and, less frequently, central nervous lesions. 
The tendons may be involved, partly from changes in the bones or 
muscles, (a) The irritative form, occurring early as acute bursitis, 
or as tendosynovitis (Fournier), is sometimes confused with rheuma- 
tism. There is more tension than pain. It occurs most frequently in 
sewing women and washerwomen, and the exudate is usually absorbed. 
(b) The gummatous form, occurring in the flexor tendons, is character- 
ized by slow growth, little pain, rarely by diffuse infiltration, and 
usually a favorable prognosis. 

(N). Mamma. — The mammae may be involved (a) by diffuse infil- 
tration, by syphilitic mastitis, with increased size, and possibly by 
tumor formation. The affection occurs largely in the secondary stage, 
and often resorbs spontaneously, (b) Gummatous mastitis is deep- 
seated and is not very sensitive. Rapid growth may be observed 
with central necrosis, fluctuation, or even external ulceration. It 
requires differentiation from adenoma, fibroma, and carcinoma; no 
glands are involved, it occurs frequently on both sides, without 
cachexia, but possibly with gummata elsewhere, and it responds to 
antisyphilitic treatment, (c) 206 cases of mammary chancre are 
recorded (Dimey). 

Abnormal Course of Syphilis. — Of special importance is malignant 
syphilis, (syphilis precox, acute syphilis, or galloping syphilis, which 
are synonymous with early development of tertiary syphilis). The 
cause may be increased virulence of the virus, or decreased physio- 
logical resistance, as in cases of tuberculosis, alcoholism and other 
cachexia?. Early ulceration, grave general symptoms and hemorrhage 
are noted. 

Relation to Physiological and Pathological Conditions.— The mor- 
tality is great in congenital syphilis (v.i.); tuberculosis, retarded 
development, idiocy, and epilepsy, may result later. On pregnancy the 
disease has a bad influence and mercury is less universally successful. 
Exanthematous diseases may cause syphilis to disappear but their 
curative influence is short. The effect of coincident measles and 
smallpox is unfavorable. Chronic diseases, as tuberculosis, are un- 
favorable and often induce the ulcerative form with early tertiary 
symptoms. Syphilitic cachexia may be complicated by tuberculosis; 
glaucoma may become aggravated, and syphilitic psoriasis may become 



HEREDITARY SYPHILIS 295 

carcinomatous. Trauma is an important and well-studied subject. 
In the treatment of fractures in syphilis, mercury is indicated. Pyaemia 
is seldom observed after operations in syphilis. Syphilis is important 
in plastic operations. Wounds may become the seat of specific ulcera- 
tion. In life assurance, the outlook is uncertain; it has been estimated 
that 11 per cent, die before their expectancy. 



Hereditary Syphilis. 

That syphilis descends only to the first generation is the general 
belief. Fournier (1905) finds 115 cases recorded in the second gen- 
eration, of which many are very doubtful. 

If both parents are diseased the child mortality is 68 per cent, and 
the morbidity is 92 per cent. 

1. Syphilis of the Child Acquired from the Father at the Time of 
Conception. — The possibility of purely spermatic (paternal) infection 
is established. It is the simplest and most frequent variety, in that 
97 per cent, of cases of syphilis occurs in men (Fournier), although a 
larger ratio occurs in women of the lower classes. It rarely occurs 
after the second year of infection has passed. The explanation is 
difficult, except on the theory that the otherwise non-infective sperma 
is infective for the ovum only. This form of transmission is more 
probable, the more recent the paternal disease. The effects are shown 
by abortion, premature birth, less frequently by syphilitic children at 
full term, or all of the above successively (the virulence of paternal 
syphilis decreasing with time). The child mortality is 28 per cent, 
and the morbidity 37 per cent., this being the most frequent and the 
most favorable form. The mother may remain uninfected. 

2. Syphilis of Child from Mother, Syphilitic at the Time of Con- 
ception. — Infection is most dangerous in the first year of the disease, 
and generally persists longer than in man. Abortions occur first, then 
premature deliveries, and finally, dead or diseased children at term. 
The mortality is 60 per cent, and the morbidity 84 per cent. 

3. Infection of the Mother and Conception Occurring Simultan- 
eously. — This form is dangerous to the child, though early treatment 
may modify the result. According to Neumann, in 29 per cent, of 
cases, the children are not viable, and 39 per cent, die soon after birth 
(i. e. f 68 per cent. die). 

4. Postconceptional Syphilis. — The child is less liable to contract 
the disease, the later the infection of the mother; it may even escape 
direct infection and only suffer inanition. The virus may pass through 
the placenta to the child, although there is a theory that the placenta, 
if not diseased, may protect the child from infection. 

Influence upon the Sound Mother of the Child Infected by the 
Father. — CohVs (or Baume's) law is as follows: The child is held to 
make the mother immune to infection; she cannot be infected from 
her infected child; she can nurse her syphilitic child without danger. 



296 THE SPECIFIC INFECTIONS 

Some exceptions exist and 30 cases are reported in which the mother 
was infected after the birth of a syphilitic child. Caspary and Neu- 
mann have widened the application of Colle's law to the statement 
that the mother cannot even be infected by inoculation from an initial 
sclerosis. In such cases it is not true, as Fournier held, that the mother 
is already syphilitic. Sound children of syphilitic parents have appar- 
ently some immunity against syphilis because of action of toxins 
(Prof eta's law, — i.e., the syphilitic mother is said not to infect the 
sound child, which theory has many exceptions). If the children 
acquire syphilis, it is said to run a mild course. It is, nevertheless, a 
fact (Grunfeld) that the sound child may become infected intra partum. 

Influence on the Child. — Abortions and miscarriages have been 
overestimated as evidences of syphilis. They are frequent in animals. 
Abortion, atrophy, maceration, retarded development, congenital syph- 
ilis or evidences of the disease after birth,- are frequent. Many chil- 
dren, born first after infection, die, though those born later may be 
sound. A difference exists between the congenital syphilis with signs 
at birth, and the hereditary type, which develops later (possibly very 
late, syphilis hereditaria tarda). Even when specific lesions are absent, 
pathological cell degeneration, rhachitis, scrofulosis, slow intelligence, 
neuroses, psychoses, and a high percentage of mortality to all diseases, 
may result. 

Symptomatology. — The primary, secondary and tertiary stages are 
not usually present and lymphatic infection does not precede that of 
the entire organism. Secondary and tertiary manifestations may occur 
in the most intimate and synchronous connection. The symptoms are 
usually recognizable at birth or soon afterward, usually after a few 
days or weeks, and almost always within the first three months. 

Appearance. — The atrophic child presents a characteristic appear- 
ance, with relaxed yellow-gray skin, poorly developed hair and bent 
or undeveloped nails (onychia). The palms of the hands and soles 
of the feet are lacquered, the voice and muscles are weak, and the 
child does not nurse well. Such children, especially when several are 
born in succession, are suggestive of syphilis, even when no lesions 
are found. Other suggestive symptoms include the heavy placenta 
whose weight compared with that of the syphilitic child is 1 to 5, 4, or 
3 (normally 1 to 6); increasing loss of weight for one to two weeks 
(normally three days), which may amount to 13 ounces; and enlarge- 
ment of the spleen. 

Pathognomonic Symptoms. — The exanthem, as in adults, is poly- 
morphous, but varieties occur which are absent or infrequent in the 
adult, such as pemphigus, hemorrhages, furuncles, and diffuse infiltra- 
tion of the skin. There is a general tendency to severe forms. The 
macular are dirty, brown-red, and often confluent, and occur on the 
face, body, extremities and in the genital region. The papules occur 
principally in the folds of the joints, in the axillae, groin and gluteal 
region and they tend to recur; papules of various ages co-exist with 
desquamation, though never with condyloma, which is always a sign 



HEREDITARY SYPHILIS 297 

of acquired syphilis. They tend to ulcerate. Psoriasis of the hands 
and soles of the feet with desquamation is common. Pustular lesions 
occur in severe syphilis and are prognostically unfavorable. They 
occur not only in the new-born but also in the immature foetus ; pem- 
phigus is a subtype of the pustule; gangrene and necrosis may occur. 
The copper-colored syphilitic infiltration especially on the nates and 
lower extremities, may often be mistaken for erysipelas. Coryza 
("snuffles") is very characteristic and almost invariable, the secretion 
being bloody and purulent, with crust formation. Fissures occur 
about the mouth, with an infiltrated base and cicatrix formation. 
Papular eruptions (erosions) occur in the mouth, especially on the 
tongue and the palate, and the tendency is toward necrosis of the bones. 
Sequels result from secretion reaching the larynx, lungs or intestines. 
Eruptions and rhagades occur about the genital and anal regions. 

Teeth. — Erosions may occur upon the surface and furrows of the 
teeth and notches may develop. The teeth are small, often irregular 
and poorly developed. Hutchinson held that the semilunar covering on 
the free edge of the upper middle incisors was pathognomonic of tardy 
hereditary syphilis, but Hutchinson's teeth occur in other affections, 
such as scrofula and rickets; they are therefore expressions of con- 
stitutional derangement and not necessarily syphilitic, though they are 
suggestive of it. 

5& Fig. 19. 




Notched teeth. Malformation of permanent teeth found in hereditary syphilis. 
(Jonathan Hutchinson.) 

Bones. — The bones, as in adults, may present characteristic findings. 
There may be periostitis, tophi or perforated palate. Osteochondritis 
occurs in various bones but especially in the lower end of the femur; 
the diaphysis and epiphysis may be separated. There is (a) over- 
growth of the cartilage of the diaphysis which produces the wavy line 
of white cartilage cells; (b) the line of cartilage cells becomes thick 
and foci of decalcification occur; (c) the cartilage is as prominent as 
it is in rickets, the part nearest the bone being soft. The immobility 
of the leg may be suggestive of paralysis. 

Viscera. — The changes are vascular or gummatous. There are 
characteristic changes in certain organs which are rarely involved in 
acquired syphilis; — e.g., in the thymus, umbilical cord, pancreas, 
lungs, intestines and adrenals. To avoid repetition and to conserve 
the classification, these changes have been described under acquired 
syphilis (Special Symptomatology). Vascular changes are especially 
marked, as in the umbilical vessels, and the tendency is toward hem- 
orrhage — syphilis hoemorrhagica neonatorum. Hemorrhages may occur 
in the skin, mucous membranes and viscera. They may be profuse, 
especially in the liver and the lungs, where the circulation is precipit- 
atelv altered after birth. Some vessels may be thickened or infiltrated 



298 THE SPECIFIC INFECTIONS 

(disease of the vasa vasorum). There is often deficient brain develop- 
ment and the posterior cerebral fossa is especially involved; the head 
may be retracted, and there are other signs of meningitis, 

Acquired Syphilis in Children ■ — vs. Hereditary. 

Less mortality and less malnutrition. Marked. 

After third month (are exceptions). Before third month. 

A primary lesion occurs. Absent. 

Secondary lesions, then tertiary. Secondary and tertiary together. 

Lymph glands enlarged. Absent (except from accidental causes 

or suppuration). 

Usual sequence of primary, secondary Snuffles, anaemia, diffuse pigmentation, 
and tertiary symptoms. pemphigus, involvement of soles and 

palms, epiphyseal changes, etc. 

Syphilis hereditaria tarda develops its first symptoms in later years, 
as for instance, at puberty. This variety is recognized by some writers 
such as Neumann, if (a) the parents are syphilitic, and if (b) the indi- 
vidual has presented no previous signs of syphilis. Most cases begin 
between the tenth and eighteenth years (rarely before the tenth and 
even after the fortieth year). Most cases are seen in private practice. 
The symptoms are mostly those of infantilism, in regard to puberty, 
bone development, teeth, and brain. 

Syphilis usually confers immunity, but this is neither absolute nor 
life-long, because (1) reinfection may occur (53 instances, Koebner) ; 
(2) in hereditary syphilis, a later infection may be acquired (27 cases 
known) and (3) a sound child of syphilitic parentage may acquire 
syphilis (29 cases reported). 

Treatment of Syphilis. 

Prophylaxis. — The disease prevails in spite of the numerous oppor- 
tunities for free treatment, for the sexual instinct is even stronger 
than that of self-preservation. Irregular intercourse is possible 
because of class differences, lack of barriers among the ignorant and 
destitute, and is promoted by the struggle for existence which often 
makes early marriage impossible. Prostitution, hidden or open, is 
the basis of syphilis. Sixty-nine per cent, of women in open houses 
have the disease for months before treatment is instituted, while hidden 
prostitution among waitresses, for example, is much more dangerous. 
In prostitutes, condylomata last as long as seven years and repeatedly 
recur about the genitalia. Continence and enforced medical inspection 
with control are the sole prophylactic measures. American sentiment 
is against licensed prostitution, which, besides, is incomplete because 
it does not regulate men nor unlicensed hidden prostitution. Many 



TREATMENT OF SYPHILIS 299 

infections are acquired under the influence of liquor. Where ethical 
considerations fail, an appeal to fear may be effectual. 

The importance of the disease lies in its long course, in the involve- 
ment of vital viscera, in its transmission to the wife and offspring 
whose mortality and morbidity are enormous, in its wide dissemination 
(13 per cent, of the population acquire the disease, and 1,650,000 
persons are infected annually), and finally in our possession of specific 
remedies. 

Marriage should be forbidden for at least two, or, better, for 
three years. Coitus must be avoided when there are recurrences. 
In cases of doubtful infection of the wife or husband, both should 
be treated. Inunctions should be given the pregnant mother, whether 
she be infected in the first or second part of pregnancy. If the 
child be diseased and the mother healthy, the facts should be laid 
before her and some would then allow her to choose whether she would 
nurse her child. Mercury should be given her. The physician should 
never countenance employing a healthy wet-nurse for the syphilitic 
child. Circumscision is thought to lessen chances of infection. 

I. Initial Lesion. — Extirpation is inefficient. The early use of mer- 
cury does not prevent the secondaries nor the recurrence of the dis- 
ease; it may lessen secondary manifestations, but it is thought that 
the tertiaries are more apt to follow weak secondary development. We 
may err in the diagnosis of hard chancre, if we employ treatment in 
the initial stage. Patients may become immune to mercury when 
results are most needed — e.g., late in the course of the disease. 
Nevertheless, the writer believes early treatment is often indicated 
when the diagnosis is certain. Local treatment includes the use of 
antiseptics, iodoform, aristol, mercurial plasters, iodoform in supposi- 
tory in rectum or vagina, bichloride washes for mouth, and calomel for 
condylomata (calomel 6 parts, boric acid 3, and salicylic acid 1 part). 

II. Seconday Stage. — In the secondary stage mercury is a specific. 
It must always be used with care; the teeth should be cleaned first, 
and bad teeth should be filled. Calomel acts especially on the lesions 
of the mouth, and is prone to produce salivation. Mercury is indicated 
for all of the irritative (i.e., secondary) phenomena of syphilis, and 
Gowers always uses it with the iodides, even in the tertiary stage, 
especially in nervous lesions. Mercury may produce bad effects (v.i.) 
in tuberculous, cachectic, alcoholic, malarial, or anaemic subjects, in 
bleeders, and in cases of galloping syphilis, in which latter, iodides are 
considered by some better than mercury. Mercury must be used with 
great care in nephritic subjects. 

Methods of Administration. — 1. By Mouth. — Ninety-five per 
cent, of cases are treated by this method in this country: (a) Calomel 
(Hydrargyri chloridum mite) is especially adapted to children with 
hereditary syphilis, who are rarely salivated under three years of age; 
gr. J to J t. i. d. plus opium p. r. n. It is insoluble, and is probably con- 
verted by the alkaline carbonates in the intestines into the gray oxide 
which is absorbed with the fats, (b) Blue mass (Massa hydrargyri), 



300 THE SPECIFIC INFECTIONS 

gr. J to 1, is milder than calomel and less irritant to the stomach, but 
produces salivation oftener than any other mercurial. Women are 
less subject to ptvalism than men. (c) Hydrargyrum tannicum oxy- 
dulatum (Lustgarten) contains 50 per cent, mercury, is non-irritant, 
does not salivate, produces less diarrhoea and is easily assimilated; gr. 
1 to lh plus pulv. opii gr. tS; id) — 

Hydrargyri protiodidi gr. xv. • 

Extr. opii gr. v. 

Extr. gentianae q. s. 

M. et ft. pilulae no. 60 

S. — One after meals. 

The Hydrarg. iodidum flavum or protiodide is mild and analogous 
to calomel. (e) The bichloride of mercury is irritating (Hydrarg. 
chloridum corrosivum); it is not prone to salivation, is absorbed by 
the intestine, and stimulates the liver. Mercury, administered inter- 
nally, produces more irritation and is less likely to be absorbed. It 
is used especially in children and in lighter forms of the disease. 

2. Inunctions. — These must be thorough and should be given where 
the skin is soft and free from hair (flexor surfaces, and never in the 
axillae, the English method). The mercury is rubbed into the seba- 
ceous or sweat-glands and is probably absorbed by the lymph-vessels. 
The skin must be cared for by daily baths. A simple diet and mild 
laxatives should be given, though, as a rule, mercury somewhat loosens 
the bowels. The rubbing should continue for twenty to thirty minutes. 
Hairy regions, the navel, the nipple, and areas of accidental eczema, 
abscess, psoriasis, or furuncle, are to be avoided. On the first day the 
inunction should be given on the abdomen, on the second day on the 
chest, on the third on the calf, then on the thigh, forearm, arm, etc. 
If an attendant gives the rubbing, his hand should be protected by a 
rubber glove. Written instructions should always be given to the 
patient. 

The number of inunctions necessarily varies with the case; twenty 
to thirty should be given for the macular and papular types; more 
than thirty, for all pustular or ulcerating eruptions, but not more 
than thirty should be given continuously. Inunctions must be inter- 
rupted for ulceration, diarrhoea, or stomatitis. Salivation is not de- 
sirable, nor is it a sign that enough mercury has been given. The 
unguentum contains 50 per cent, of mercury, and the more elegant 
oleatum but 20 per cent., which should be considered, as about 5ss 
of mercury should be incorporated daily. 

Lnguent. hydrarg o iv. 

Div. in dos. sequal. no. .... xxx 

Dent, ad cartam cerat 

S. — One as directed daily. 

In children, mercurial ointment may be applied on a binder (West- 
lander) and allowed to remain for many davs. The ointment is some 



TREATMENT OF SYPHILIS 301 

times also applied to the feet, and the friction of walking rubs the mer- 
cury in. The advantages of inunctions are as follows: they cause 
almost no digestive disturbance; they are especially good in children; 
they are the most rapid method, and are attended by the least general 
bad effects. The disadvantages are publicity, troublesomeness, and 
dirtiness, all of which, however, are but relative objections. 

3. Injections. — A great diversity of opinion exists as to the value 
of injections. Other methods should at least be used first. Their 
advantages are prompt action and exact dosage. Intravenous injec- 
tions may be imperative in cases with coma and other urgent symp- 
toms. The disadvantages are the risk of embolism, suppuration, 
sloughing, and pain; once given, their action cannot be regulated 
or decreased. The soluble salts are best: 

Hydrarg, chlorid. corrosivi 1.00 

Sodii chloridi ...... 10.00 

Aquae dist 100.00 

One c.c. daily equals 0.01 gm. or gr. J of HgCl 2 ; five to forty injec- 
tions are usually necessary. 

4. Baths. — 5ij to iij. of HgCl 2 to a full bath is useful for skin lesions, 
such as syphilitic psoriasis. 

5. Fumigations. — Four ounces of calomel should be vaporized, and 
the fumes held to the exposed body by heavy coverings. The method 
is impracticable. 

Mercury is incompatible with nearly everything. Coincident anaemia 
is treated by iron, strychnia, sarsaparilla, and arsenic. Syphilitics tol- 
erate mercury well, in large doses, and for a remarkable period. In- 
deed, they sometimes seem to develop an immunity to its action. It 
is not out of place, however, to consider briefly the general action of 
the drug; in the smallest doses it is tonic, for it increases the number 
of red cells. In small doses there develops a symptom-complex 
known as salivation, of which peculiar fcetor is first noted; then sore 
teeth, metallic taste, red gums which are swollen, spongy, and bleed 
easily, and increased saliva, follow. The drug is never given beyond 
this point. In larger doses the tongue becomes swollen, the gums 
inflamed with a red line and great vascularity ; the teeth become loose ; 
the saliva is increased greatly, is viscid and stringy; the salivary glands 
become intumescent; there is low fever; fugaceous eruptions appear, 
resembling those of eczema, scarlatina, measles, and more rarely, pur- 
pura and pemphigus. Severe salivation results in loss of teeth, great 
stomatitis, necrosis of jaw, ulceration of the mouth and contiguous 
parts, marked changes in the blood, and profound exhaustion. The 
treatment consists of potassium chlorate as an antiseptic mouth wash, 
and such astringents as tr. myrrh and tannic acid. 

III. Tertiary Stage. — Iodides are specific in this stage. They are 
sometimes used in the secondary stage (v. s.) especially in febrile 
cases, in secondary osseous and nervous manifestations, and in weakly 
persons with a marked macular eruption. Iodides do not operate 



302 THE SPECIFIC INFECTIONS 

very specifically in the tertiary stage when no mercury has been given 
during the secondaries. It acts more slowly than mercury; it acts 
not only as a specific, but also is useful in removing mercury from its 
loose, protoplasmic union with the gummata. It is especially indi- 
cated when the bones, nervous system, and viscera, are seats of gum- 
mata, and when the general health is broken. Patients may acquire 
immunity to iodides, and its use should therefore be intermittent and 
should alternate with mercury. Mercury is conjointly employed when 
organs of great importance are involved, such as the larynx, brain, 
and eye. 

The therapeutic tests for syphilis are (a) cure with mercury and 
iodides; (b) tolerance by the patient of very large doses of iodides. 
Regarding their diagnostic value, Gower's criteria are: (1) that the 
influence of the drugs must be unequivocal and fairly immediate. 
(2) That no other remedy be used. (3) That spontaneous remissions 
which are seen in other diseases (such as brain tumor), must be ex- 
cluded. (4) That the remedies used must not operate on any disease 
other than syphilis. (5) Before negative conclusions are drawn re- 
garding the syphilitic nature of the lesion, it must be remembered 
that loss of tissue, which occurs in arterial occlusion, and paralysis 
from brain softening, cannot be restored. 

The different iodides contain the following percentages of iodine: 
KI, 75.5 per cent.; Nal, 84.6 per cent.; Lil, 95.5 per cent.; Ami, 87 
per cent. 

Sodium iodide is milder, produces less iodism, has a less bitter 
taste, and has less effect on metabolism than potassium iodide, which, 
however, is better than other iodides (Schmiedeberg), though it irri- 
tates the stomach and bowels, depresses the muscles, and disturbs the 
motor nerves. 

The following proportions for a single dose may be employed when 
no urgency demands large doses: 

Potassii iodidi gr. xv (gm. 1.0) 

Hydrargyri chloridi corrosivi gr. 1/32 (gm. 0. 002) 

Tincturae opii ttjj. 2 (gm. 0. 13) 

Syrupi aurantii corticis 5ss (gm. 2. 0) 

M. et S. — After meals in a glass of water. 

Large doses of iodide are sometimes given in urgent cases 5 ss ~3j 
t.i.d., to break down more rapidly the new-formed granulation tissue. 
The author believes that enormous doses are unnecessary and are 
not without danger (v.i.). Iodide dissolves in its own weight of water; 
hence one minim of a saturated solution equals one grain of iodide. 
It is best disguised by Syr. sarsaparillse co. dr. ss and Tr. iodi m 1; 
also by peptonized milk, aerated waters, currant, orange, or raspberry 
syrups, beer, sassafras, licorice, or anise oil. 

Iodism is often produced by small doses, and usually ceases with 
larger ones. It is obviated by intermittent administration, by daily 
baths, by stimulating with water the kidneys, the inactivity of which 
is the usual cause, by giving aromatic spirits of ammonia, or arsenic 






TUBERCULOSIS 303 

and belladonna. Iodism is likely to occur in renal disease. Its leading 
characters are: (a) Increased secretion from the eyes, nose, mouth, 
salivary glands, bronchi, stomach, bowels, skin, and kidneys. The 
eyes, throat, larynx, and salivary glands swell. The writer once nearly 
suffocated from oedema of the pharynx and uvula after ingestion of 
10 grains of iodide for a cold. Laryngeal and pulmonary cedema and 
albuminuria, or even nephritis, may develop. (6) Gastric irritation, 
(c) Nervous depression, mental derangement, or excitement. These 
result especially from the potassium salt, (d) Acne, hemorrhages, 
blebs, and telangiectases in the skin, (e) Cachexia and anaemia, 
especially in goitrous subjects; emaciation, wasting of mammae and 
testes; fever, increased pulse, nervousness, and neuralgia of the fifth, 
and other nerves which pass through bony canals. 



TUBERCULOSIS. 

Definition. — A specific infection, characterized (a) etiologically by 
the Bacillus tuberculosis, (b) pathologically by nodes or tubercles, or 
diffuse tuberculous infiltration, and (c) clinically by symptomatology 
varying with the tissues or organs invaded. The term tuberculosis 
has special reference to the tubercles, but in the light of our present 
knowledge, to tubercles caused only by the Bacillus tuberculosis. 

History. — The term phthisis (wasting) was first used by Hippo- 
crates. The history of tuberculosis includes several epochs: Epoch I. 
The anatomical tubercle was recognized by Sylvius (1614-1672), 
Morton (1689) whom some consider the real pioneer, Mangetus (1700), 
Bayle (1810) who specially described the miliary tubercle. Laen- 
nec, the pupil of Bayle, in 1819, spoke for the unity of phthisis. Vir- 
chow threw the weight of his influence for Laennec's views, but in 
1847, showed that caseation was only a retrogressive change and not 
necessarily tuberculous. In 1857, Buhl described a case of miliary 
tuberculosis arising from old foci of caseation. Cruveilhier, Rilliet, 
and Barthez identified scrofula and tuberculosis. 

Epoch II was opened by Villemin (1865) who positively established 
the inoculability of tuberculosis by experiments on animals. Klenkpe 
(1843) made successful inoculations, but Villemin absolutely proved 
his point. It is interesting to note that from the time of Hippocrates, 
Aristotle, Aretaeus, and Galen, tuberculosis was feared as a contagion, 
and the older pathologists, as Morgagni, dreaded to section phthisical 
subjects. Villemin's formulations met great scepticism and opposi- 
tion, but were supported by Fox, Charcot, Grancher, and Thaon, and 
were corroborated by Cohnheim and Salamonson. The histology of 
the tubercle was developed by Wagner, Schueppel and Virchow; Lang- 
haus fully described the giant cells previously seen by Virchow and 
Rokitansky; tubercles were found in. lupus (Friedlander, 1S75), in 
lymph-glands (Schueppel, 1871) and in fungus joints (Koester, 1876). 
The firm and ancient belief in its contagiousness led to the successful 



304 THE SPECIFIC INFECTIONS 

search for the cause. It seems strange that some, as Aufrecht, Baurn- 
garten and von Ziemssen, still practically deny the infectivity of tuber- 
culosis. 

Epoch III began with Koch's announcement, in 1882, of the tubercle 
bacillus. His report was so complete that scarcely a single essential 
point has since been added to his initial communication. The bacillus 
was found in all tuberculous lesions, such as chronic phthisis, miliary 
tuberculosis, intestinal ulcers, scrofulous lesions, bone and joint dis- 
ease, lupus, and in the sputum, in cattle, etc.; it occurred in no other 
disease; it was cultivated by him and inoculated into animals with 
reproduction of tuberculosis. 

Bacillus Tuberculosis. — 1. Morphology. — It is a thin, narrow rod, 
measuring \ to \ of the red blood-cell (1^ to 4^ long) and more often 
slightly bent or curved than straight; it contains no spores, the light 
unstained areas in its body being vacuoles or spots of degeneration; 
it is generally considered immotile; in young cultures it is shorter 
than it is in the sputum, or in older growths; in old cultures and in 
lung cavities it is longer and is frequently thread-like; it occurs singly 
or in groups and bundles. Pleomorphism : variations in form are 
often noted, as bulging sides or ends, thread-like or branching forms 
and even forms said to resemble actinomyces. [See Figure under 
Pulmonary Tuberculosis.] 

2. Staining Reaction. — It stains slowly, except at body-heat, and 
once stained gives up the dye reluctantly. ZiehFs solution is the best 
for clinical purposes (Fuchsin 1, Absolute alcohol 10 and 5 per cent, 
carbolic acid solution 100). The sputum is spread out in a dish over 
a black background and the yellow-green areas selected are thinly 
distributed on the slide which is held in the hand, and is heated until 
dry at some distance from the flame ; it is then stained by the carbol- 
fuchsin, being passed repeatedly but lightly through the flame (with- 
out boiling) to deepen the stain; it is then washed, treated with 
Gabbett's stain (1 part methylene blue to 100 parts of 25 per cent, 
sulphuric acid) for ten to thirty seconds, washed well, and dried. If 
the sputum is thick or if previous examinations were negative, quan- 
tities of sputum (15 c.c.) with twice their bulk of water (30 c.c.) are 
treated with caustic potash (8 drops of a 10 per cent, solution), are 
shaken and allowed to settle for some hours, after which the supernatant 
fluid is decanted, and the sediment is examined directly or after centrif- 
ugation. Spengler digests the sputum with pancreatin instead of 
using potassium hydrate. The bacillus resists destaining because of 
its fat, an almost pathognomonic feature. For clinical purposes only 

(a) the bacilli found in bronchiectasis and gangrene of the lung (q. v.), 

(b) the smegma bacillus and (c) the leprosy bacillus, need be consid- 
ered; the leprosy germs are intracellular, cover the nucleus of the 
containing cell, and are stained in six or seven minutes with alcoholic 
fuchsin, while tubercle bacilli are extracellular, stain slowly, and require 
more time (by the cold method) than that specified; the smegma bacil- 
lus causes many errors in genito-urinary examinations; it grows 



TUBERCULOSIS 305 

rapidly in twenty-four hours, does not show the beaded appearance 
which is seen in the Bacillus tuberculosis, and when stained and 
counterstained in the usual way, becomes tinged with methylene blue 
(Weiehselbaum) . 

3. Cultures. — These develop best at body heat in one or two weeks; 
blood serum is the best medium, but growths are also successful on 
bouillon, glycerine-agar, and potato; they are dry, thin, grayish, and 
scale-like. The germ is a facultative aerobe and multiplies by trans- 
verse fission. It seemingly does not lead a saprophytic life in nature, 
outside the bodies of animals and of man. 

4. Chemistry and Metabolism. — It contains 2 to 16 times as much 
fat as other bacteria. Aronson holds that a waxy substance envelops 
the bacillus; its other constituents are proteids, a glycogen-like sub- 
stance, cellulose, nucleic acid, water, and ash; it also develops tuber- 
culin whose chief components are peptone, albumose and alkaloidal 
substances; it is soluble in glycerine. 

5. Resistance. — Its resisting powers are as a rule limited, (a) Dry- 
ing is endured by the bacillus for a few months (six or even ten months). 
In decomposing media its average life is one to one and a half (pos- 
sibly six) weeks, (b) Heat (106°) kills it in a few minutes, (c) Cold 
is fairly well resisted and it may survive 14 below zero for weeks, (d) 
Sunlight kills the bacillus in a few minutes to a few hours. 

6. Virulence. — Koch was inclined to assume that it had an equal 
virulence independent of the source of the germ, while the Arloing 
school finds that it has an attenuated virulence in glandular and osseous 
lesions, and Theobald Smith holds that bovine cultures are more viru- 
lent for rabbits than is human sputum. 

7. Agglutinating Properties. — Arloing and Courmont (1898) found 
that serum from inoculated rabbits or goats, agglutinized tubercle 
bacilli in a dilution of 1 to 5 or 20, in two to twenty-four hours; eight to 
twelve day cultures, grown on 6 per cent, glycerin-bouillon with 1 per 
cent, peptone, gave the best results; agglutination was noted in 95 
per cent, of the cases of lung tuberculosis and in 50 per cent, of the 
cases of surgical tuberculosis. Its differential value has not, however, 
been generally conceded. 

8. Associated or Mixed Infection. — This has been much emphasized 
by Ortner, Weiehselbaum, Struempell, Roger, Dieulafoy, Mosney, 
Marfan, Osier, Wolf, Spengler, and King, though Straus, Ley den, 
Baumgarten, Fraenkel and Troje lay but little stress upon it. Sym- 
biosis has been noted with the streptococcus, staphylococcus and pneu- 
mococcus, to a lesser degree with the Bacillus pyocyaneus, influenzae, 
prodigiosus, pseudodiphtheriae, Friedlander's bacillus, proteus vul- 
garis, micrococcus tetragenus and sarcinse, aspergillus, streptothrix, 
ameebse, and monads. 

9. Number of Bacilli. — Large numbers are found in fresh tubercles; 
few are found in chronic articular, osseous, or glandular lesions, and 
inoculations may be necessary to demonstrate the nature of long- 
standing lesions. 

20 



306 THE SPECIFIC INFECTIONS 

Prevalence in Man. — Tuberculosis is the greatest foe of man; it 
causes 14 per cent, of all deaths, and 33 per cent, of deaths between 
fifteen and forty-five years of age; it causes more deaths than war, 
famine, plague, cholera, yellow fever, and smallpox combined; in 
Germany, in 1894, the deaths from diphtheria, croup, measles, scar- 
latina, pertussis, and typhoid, together, were 7,000 less than those from 
tuberculosis. Five million die yearly from this plague, one million in 
Europe, seventy thousand in England, 150,000 in France, 150,000 in 
the United States, and 170,000 in Germany. Postmortem and hos- 
pital statistics do not exactly depict the tuberculosis situation; in 
Austria, the general death-rate from tuberculosis is 11 per cent.; the 
hospital rate is 25 per cent., the patients being drawn from the poorer 
classes. The true total is obtained by multiplying the annual death- 
rate by the average duration of life (three years). 

Quiescent (latent) and healed tuberculosis is found in many post- 
mortems upon those dying of other diseases; Heitler, of Vienna, found 
obsolete pulmonary tuberculosis in 4.8 per cent, among 16,562 autop- 
sies. Latent tuberculosis occurs in 25 to 33 per cent, of the population 
(Baumgarten, Birch-Hirschfeld and Bollinger), 39 per cent. (Harris) 
and 50 per cent. (Cruveilhier, Roger, and Dejerine). O. Naegeli found 
gross or microscopic evidence of tuberculosis in 97 per cent, of all 
necropsies. Recently Franz obtained a tuberculin reaction in 61 per 
cent, of apparently healthy recruits. 

Prevalence in Animals. — (a) Cattle. — In Germany, it is found in 
from 4 to 20 or 30 per cent.; in Leipsic, it even reached 20 per cent, 
in bullocks and 48 per cent, in cows. Calves are less frequently dis- 
eased. In New York, the tuberculin test was positive in 17 per cent. 
In 1898, Theobald Smith, and later, Koch, contended that bovine and 
human tuberculosis were separate infections; opinions are still divided 
on this subject, though most writers incline to the view of Smith and 
Koch. In cattle, tuberculosis is less often attended by softening of 
the tubercle, and the serous membranes are more often involved; the 
lungs and pleurae are involved in 40 per cent., the lungs alone in 20 per 
cent., and the pleurae and peritoneum in 15 per cent, of tuberculous 
cattle, (b) Swine are affected more often in Europe than in this 
country; in Saxony tuberculosis occurs in 1 per cent, and in Copen- 
hagen and Dantzig, in 11 per cent.; because their infection commonly 
results from eating tuberculous offal, the type is usually alimentary 
(90 per cent.), (c) Other mammals. — Dogs and cats are seldom dis- 
eased except from contact with man; the type in dogs is respiratory 
(83 per cent.). Horses, sheep, and goats, are rarely diseased. Monkeys 
in captivity die frequently (43 per cent.) from tuberculosis, referred 
by Dieulafoy and Krishaber to foul cages, (d) In reptiles, it is rarely 
seen, except in those in captivity, (e) In most birds, tuberculous lesions 
are more frequent in the liver, spleen, intestine, mesenteric glands, 
bones, and joints, than in the lungs, though parrots suffer from skin 
and lung localization. In avian tuberculosis the bacilli grow rapidly, 
present greater morphological variability, and live longer, which char- 






TUBERCULOSIS 307 

acters seem to justify their separation from the human type. Man 
may apparently become infected (Pancini), and there are those who 
still contend for the unity of the human, bovine, and avian bacillus-. 
Tubercles are not uncommon in animals from nematodes, protozoa, 
and bacteria, and are designated pseudotuberculosis. In man, Flexner 
has described a streptothrix pseudotuberculosis causing caseous pneu- 
monia and peritoneal nodes; the streptothrix differed both from the 
tubercle bacillus and the ray fungus. An aspergillus tuberculosis has 
been described (v. diagnosis Tuberculosis of Lungs). 

Atrium. — The details will be especially considered under the dif- 
ferent clinical localizations of the disease. 

1. By the Respiratory Tract. — The bacillus enters the respiratory 
tract by inhalation. In the vast majority of cases the sputum of dis- 
eased persons is causative both of the disease, and its great frequency 
of localization in the respiratory organs. It has been estimated that 
a phthisical person voids 7,200 millions of tubercle bacilli daily. As 
the expired air is proven germ-free, the sputum must be the chief 
factor in dissemination. Cornet holds that the greatest danger lies 
in the drying of the sputum in the room, on the handkerchief, on the 
lips, beard, hair, fingers, and clothing, though Fluegge contends that 
dried sputum is less dangerous than the moist expectoration. Fluegge 
demonstrated that in coughing, which seemingly voids no secretion, 
in singing, in sneezing, or talking, small and almost invisible drops of 
moisture containing the bacilli are voided, and he has cultivated 
bacilli from glass plates which were covered with solid culture media 
and held near the patient ; he believes that minute particles remain in 
suspension in the air and thus infect other individuals. Drying of the 
sputum voided in the street or other open places is less significant than 
was formerly thought, since the sun soon kills the bacilli. Hence the 
ubiquity of the tubercle bacillus is generally exaggerated though it 
is of great importance in poorly ventilated, dark dwelling-rooms, hos- 
pitals, cloisters, hotels, or prisons, which are frequented by victims of 
tuberculosis. Cornet found the bacilli in the dust of such rooms in 
large numbers, yet in about 10 per cent, of tuberculous wards no bacilli 
were found; he experimentally demonstrated that animals confined 
in rooms with dried tuberculous sputum readily acquired tuberculosis. 
Straus, of Paris, collected the germ from the nose in 31 per cent, of 
the attendants in tuberculous wards. According to Cornet, infection 
is less frequent than might be expected, because the mucus and the 
bacilli absorb moisture from the air, and their hygroscopic properties 
thus make them resistant to drying. The closer the contact with 
tuberculous subjects, the greater is the danger of infection, as tuber- 
culosis is surely an infection. In crowded prisons, the death-rate is 
three or four times that of the general community; in Austria, for 
example, the general mortality is 11 to 15 per cent., and the prison 
mortality is 40 to even 60 per cent. In nursing sisterhoods, Cornet 
found the death-rate ranged from 63 to over 75 per cent. Six cases 
were observed by the writer, in two years, in one small, closely 



308 THE SPECIFIC INFECTIONS 

cloistered community. In Philadelphia, Flick's studies showed that 
33 per cent, of infected houses contributed more than one case. In 
Falkenstein, Germany, and Brompton Hospital, London, acquisition 
of tuberculosis by attendants is infrequent, while in Paris, Straus puts 
their mortality at a high figure. In our dispensary service, seven 
rapidly fatal cases were observed in one family which had no heredi- 
tary stigma nor previous disease (Harpole). Oral breathing, caused 
by adenoids, inhalation of coal-dust or stone-dust, syphilis, cancer, 
and leprosy, are favoring factors. 

Dusting, sweeping, or shaking the bed clothes, disseminates the 
virus; there is less danger of infection when the windows and doors 
are open and when dusting is done with moist cloths rather than with 
feather-dusters. In hospital wards there are more germs in the air 
during the cleaning hour than during the o'ther twenty-three hours. 
However, if bacilli are in the dust, they are not necessarily in the 
inhaled air; if inhaled, they do not necessarily reach the lungs, for 
they may be caught in the upper air-passages whose secretions antago- 
nize their development, and are often waved back by the ciliated 
epithelium of the lower air-passages. Cornet holds that the state- 
ment that " every man lives in the environment of tuberculosis" is 
surely exaggeration. Married persons, because of their intimate asso- 
ciation, may contract the disease from each other, as was noted by 
Ettmueller and Morton, in the seventeenth century; the husband 
more often conveys infection to the wife than the wife to the hus- 
band; in Weber's series of cases, a husband lost four wives, another 
three wives, and in four other cases two wives contracted tuberculosis. 
The danger of sleeping and living together is somewhat overdrawn, 
as the family members are less together than is at first ap- 
parent. When bacilli are inhaled into the respiratory tract (a) no 
lesions may result, (b) the lungs may become diseased, or (c) the 
germs may pass the mucosa of the mouth or bronchi and cause 
glandular tuberculosis — e. g., cervical or peribronchial adenitis tu- 
berculosa. 

2. By the Digestive Tract. — Milk is most dangerous (Gerlach, 
Bollinger, Bang, and others), though lately attempts have been made 
to minimize the danger from this source of infection. It was formerly 
thought that, in cows, a tuberculous mastitis was necessary to milk 
infection, but Ernst and others demonstrated that milk may be infec- 
tive from cows with tuberculosis which does not invade the udders. 
Pigs, fed on tuberculous milk, develop intestinal tuberculosis. Butter 
may contain tubercle bacilli. Meat is less dangerous, as it is usually 
well cooked, but tubercles in raw offal frequently infect swine. Bacilli 
may pass the mucosa, especially in children, and produce the first 
lesions in the mesenteric glands. 

3. Direct Inoculation. — Inoculation through the skin, eye, genito- 
urinary tract, by trauma, or operations, is far less significant and will 
be considered under the various tissues occasionally involved. The 
point of entrance is often hard to find. 



TUBERCULOSIS 309 

Predisposing Factors. — These are important, but if practically con- 
sidered, tuberculosis is best prevented and treated as an infection, 
communicated and acquired by direct personal contact. 

1. Heredity. — 1. Hereditary Predisposition to Tuberculosis. — This 
is shown by the frequency with which a tuberculous family history is 
obtained in infected individuals, and is estimated at 25 per cent. (10 
to 85 per cent.). It is remarkable what statistics can be made to estab- 
lish, and if moved by theory alone, one might prove by figures a 
formidable hereditary influence in measles, pneumonia and other com- 
mon diseases. Kuthri found essentially the same percentage of family 
tuberculosis in non-tuberculous as in tuberculous cases. Tuberculous 
parents may infect their children (50 per cent.), as they may infect 
others, but the children usually (97 per cent.) escape the disease when 
removed from their parents. According to Rieffel, 3 per cent, of chil- 
dren acquire tuberculosis when both parents are sound, 22 per cent, 
when both parents are tuberculous, 10 per cent, when the mother and 
7 per cent, when the father is tuberculous. Whatever stress may be 
laid on statistics, hereditary predisposition is no obstacle to preven- 
tion and treatment. 

2. Congenital Tuberculosis. — It is thought by Baumgarten that chil- 
dren actually inherit the bacillus, which remains latent, possibly for 
years, and then develops an active tuberculosis. If his views are cor- 
rect, we are confronted with a difficult problem. Considering the 
possibilities of bacilliary inheritance, congenital tuberculosis can be 
acquired only through (a) the spermatozoon, (b) the ovum or (c) pla- 
centa, (a) The spermatozoon is a nuclear structure which is not 
proven to be attacked by the tubercle bacillus, though the bacillus is 
sometimes found in the semen in genito-urinary tuberculosis, (b) The 
ovum has, in rare instances, been infected, but Virchow, among 
others, questions this possibility. Mafucchi found that tuberculosis 
developed in chicks, weeks or months after the ova, from which they 
were hatched, were infected. (c) Placental tuberculosis has been 
observed clearly in about 22 human cases (according to Warthin and 
Cowie in only 5), and slightly over 100 cases in animals (Friedman, 
1905). The first indisputable case was that of Schmorl and Birch- 
Hirschfeld which was confirmed by the inoculation and finding of 
the bacillus. The maternal and fcetal circulations are quite distinct, 
but toxaemias may occasionally allow the virus to pass to the foetus, 
that is, in typhoid, scarlatina, smallpox, or anthrax. Placental trans- 
mission is observed more often in animals (^ to 1 per cent., Klepp). 
Usually there is a placental focus before the foetal blood is infected, 
but the bacillus may sometimes pass directly to the foetus. Placental 
infection is possible, but is so infrequent that many experienced ob- 
servers, like Virchow, have never seen a case. However, Schmorl and 
Geipel recently found tuberculosis in nearly 50 per cent, of placentae 
of tuberculous mothers. 

The arguments against hereditary tuberculosis are (1) that children 
born with the disease die very early; (2) that tuberculosis in the first 



310 THE SPECIFIC INFECTIONS 

months of life is extremely rare; (3) that the disease seldom remains 
latent until adult life, as most cases of infantile tuberculosis develop 
during the period of special growth, namely from the second to third 
year; (4) in congenital infection, the liver is chiefly diseased because 
of the nature of its vascular relations to the placenta; in tuberculosis 
of children, the lungs, glands, and other organs, are more often dis- 
eased, — i.e., the infection is respiratory, and therefore, extra-uterine. 
(5) When removed from their tuberculous parents, children thrive well. 

II. Environment. — This covers many points which were mentioned 
under Atrium. Dampness and poor drainage, emphasized by Bow- 
ditch and Buchannan, are factors which reduce the physiological 
resistance. Trudeau's experiments show that inoculated animals, kept 
in dark, damp cellars, die, while others, allowed to run at large, out- 
live the infection. Density of population raises the proportion of 
tuberculous cases. In recent years the large cities have shown an 
apparent decrease of tuberculosis, as shown by Edward F. Wells, of 
Chicago, and Jas. B. Russel, of Glascow. It has also decreased in 
New York and London. In Massachusetts the total is less by half 
than it was fifty years ago. The decrease is attributed to more intelli- 
gent hygiene. The figures show a decided decrease in Chicago (v.. 
Pneumonia); it is possible, in recent years at least, that this is ex- 
plained by the fact that pneumonia carries off the less resistant of the 
population. In Munich, the death-rate from tuberculosis was 12 per 
cent, at a time when typhoid was epidemic; when typhoid was prac- 
tically abolished, the. tuberculosis rate increased to 16 per cent., — 
i.e., 4 per cent, of those with tuberculosis had previously died from 
typhoid. 

III. Occupation. — Occupations involving work in close, damp 
rooms, in dust, in crowded quarters, particularly when associated 
with poor food, alcoholism, worry, and over-exertion, promote tuber- 
culosis when exposure to infected individuals exists. Clerks, steno- 
graphers, or waiters, are naturally more easily infected than are those 
working in the fresh air, for example, cab-drivers. It is rather sur- 
prising that miners do not suffer more frequently, but the explanation 
of this is the dampness, which prevents the drying of infected sputum. 

IV. Age. — Cornet's figures show the following death-rate per 10,- 
000 of population : first year 2 to 3, the child being in close contact 
with the mother. These figures grow smaller, until the lowest figure is 
reached, namely, ^, between the fifth to tenth years ; fifteenth to twen- 
tieth years, 17 to 19; twentieth to thirtieth years, 32 to 36; thirtieth to 
fortieth years, 44; fortieth to fiftieth years, 55; fiftieth to sixtieth 
years, 76; sixtieth to seventieth years, 100; seventieth to eightieth 
years, 70; over eightieth year, 20. In the first decade of life, glandular, 
meningeal, osseous, cutaneous, and articular tuberculosis are more 
frequent; the mucosae are more permeable and the lymph channels 
wider, so that infection is very often first evidenced in the lymph glands. 

V. Sex. — Between five and twenty years of age, girls are more prone 
to tuberculosis, because their life is more sedentary. After twenty 



TUBERCULOSIS 311 

years males more often contract tuberculosis, because of their greater 
exposure to infection. Repeated pregnancies and protracted lactations 
may favor infection by lowering physiological resistance. Skin lesions 
are more frequent in women; lupus, for example, occurs in 68 per 
cent, (in males in 32 per cent.); tuberculosis of the nose, mouth, and 
throat, is less frequent in women (4 per cent.) than inmen (81percent.). 

VI. Climate. — Warm, dry climates, high altitudes, and lack of sud- 
den variations in temperature, are generally held to reduce tuberculosis. 
Of late they are apparently considered less beneficial. The French 
Alps were long free of tuberculosis until crowded by infected subjects, 
and the same seems true of other localities. Some writers even hold 
that the chief advantages of many resorts is their sparse population 
and inaccessibility. 

VII. Race. — In this country the Irish and negroes are most fre- 
quently diseased. The Indians have justly come to dread the " cough- 
ing white man," and they die in large numbers from consumption, 
particularly in their Eastern reservations. Infection among Jews is 
peculiarly infrequent. 

VIII. Individual Predisposition. — This was considered important 
by the oldest medical writers, who described the winged scapulae, the 
paralytic thorax, and the depressed sternum; but poor thoracic and 
general development is very often an expression of already existing 
tuberculosis; phthisis often occurs in splendidly developed chests, ex- 
posure to infection being the most important factor. Tuberculosis 
confers no immunity to relapses or to new localizations; a lung lesion 
may heal while a coincident intestinal lesion progresses. 

IX. Trauma. — This is a somewhat determining factor. Bacilli in 
the blood may be localized in a bone or joint by trauma; a blow on the 
head or spine may initiate meningitis in a tuberculous subject; pleurisy 
or pulmonary tuberculosis may be initiated by injury to the chest, 
which is thought to awaken latent lesions in the peribronchial glands. 

X. Other Factors. — These are (1) diabetes, in which 23 to 50 per 
cent, die of tuberculosis of the lung; (2) psychoses, especially of the 
depressive type, as melancholia; (3) anaemia, which, however, is more 
often the result than the cause of tuberculosis; (4) inflammation of 
the mucous membranes, acute processes, such as heavy colds, measles, 
and pertussis, and less often scarlatina, influenza, or diphtheria, may 
predispose to infection, or they probably more often awaken slumber- 
ing glandular tuberculosis by the irritation of the mucous membrane 
by products absorbed from the bronchi or lungs. Enterocolitis in chil- 
dren, or typhoid in adults, may in a similar way awaken or initiate 
abdominal tuberculosis. Smallpox and eczema sometimes seem to 
produce similar effects on the skin. (5) Contracted kidney, cirrhotic 
liver, sclerosed arteries, stenosis of the pulmonary artery, aortic aneu- 
rysm and narrowed hypoplastic aorta are predisposing factors. As 
Rokitansky first pointed out, valvular disease of the left heart prevents 
or checks infection, because it congests the lungs; Bier's treatment of 
surgical tuberculosis, by inducing congestion through ligatures, is based 



312 THE SPECIFIC INFECTIONS 

on this point; Birch-Hirschfeld, in 4,359 autopsies, found chronic pul- 
monary tuberculosis in 21 per cent., and in 107 autopsies of valvular 
heart disease, it was present in but 2.8 per cent. Potain, in 54 cases of 
mitral stenosis, found pulmonary tuberculosis in 16.6 per cent, (see 
Valvular Disease of the Heart). (6) Syphilis, pleurisy (q. v.), 
and haemoptysis (q. v.), are occasional predisposing factors. 

General Histo-Pathology of the Tubercle. — The only absolutely 
pathognomonic feature of the tubercle is Koch's bacillus, as similar 
infective granulomata are seen in strongylus in sheep, in actinomycosis, 
and in syphilis. Baumgarten described the changes following inocu- 
lation of the anterior chamber of the eye: (a) On the first day the 
bacilli increase and spread somewhat along the lymph-spaces. (6) 
By the sixth day, the fixed connective-tissue cells proliferate under the 
stimulus of the tubercle bacillus, which acts as a foreign body; these 
cells, known as epithelioid cells, are large, rounded or polygonal cells 
with distended nuclei, and sometimes contain tubercle bacilli; in 
another day or two they show karyokinetic figures ; the bacilli multiply 
and the endothelial cells of the vessels proliferate. The tubercle of 
this stage is sometimes called the epithelioid tubercle, (c) On the 
tenth or eleventh day the leukocytes emigrate. This inflammatory 
reaction results from the toxins secreted by the bacillus; at first 
most of the white cells are polymorphonuclear, many of which degen- 
erate; later they are mononuclear, which do not suffer retrogressive 
changes; the mononuclears crowd the epithelioid cells and dominate 
the histological picture, especially with complicating trauma (lymph- 
oid tubercle), (d) The reticulum of the tubercle consists of the 
stretched fibers of the infected tissue or of coagulation necrosis, (e) 
The epithelioid cells increase in size and are often multinucleated. 
From them or from the extravasated leukocytes, by growth, or by 
fusion, giant cells develop; they contain many large, oval, vesicular 
nuclei and tubercle bacilli; the bacilli may number 50 to a cell in very 
active processes but are few in chronic tuberculosis; the giant cells are 
particularly abundant or may even be the chief histological finding in 
chronic forms, such as lupus, scrofulous glands or fungoid joint-dis- 
ease; they are few or absent in acute processes, as in miliary tuber- 
culosis; there seems to be a certain antagonism between the nuclei 
and bacilli, for if the nuclei lie on the margin of the cell, the 
bacilli are centrally grouped, and if the nuclei lie at one pole of the 
cell, the bacilli concentrate at the other pole. The cellular inclusion 
of the bacilli is considered a phagocytosis by Metschnikoff, which 
Baumgarten, however, denies. The completed miliary tubercle is 
non-vascular, cellular, millet-seed (miliary) in size, gray in color, and 
translucent. It is the pathological unit of all tuberculous lesions, 
however extensive. In the diffused inflammatory tubercle, the dif- 
fuse areas result from fusion of myriads of miliary tubercles (see 
Caseous Pneumonia) . 

The tubercle then undergoes one of two degenerations, caseation or 
induration: (1) Caseation results from degeneration of the tubercle, be- 



PLATE V. 




Retinal Findings in the More Important Diseases. 



1. Retinitis diabetica. 2. Atrophy (and pigmentation) of retina 
and optic nerve. 3. Choked disk in brain tumor. 4. Optic 
neuritis in meningitis. 5. Medullated nerve fibers (normal). 



TUBERCULOSIS MILIARIS ACUTA 313 

ginning at its centre, from ischsemia (vascular obliteration) and from 
coagulation necrosis (action of the bacilli and its toxins). The area of 
coagulation necrosis then gradually becomes more yellow and granular, 
and finally results in an amorphous, homogeneous, cheesy debris. Casea- 
tion is a dangerous, destructive degeneration. (2) Induration, sclerosis 
or encapsulation, results from growth of connective tissue around the 
tubercle or conglomeration of tubercles; it limits the tubercle, is the 
measure of the resisting power of the surrounding tissue, and is a con- 
servative process. It occurs most frequently in the peritoneum, but 
also in the lungs and other tissues. Inflammation, varying with the 
tissue involved, may cause other histological findings. Suppuration 
may result from mixed infection with streptococci, though Koch held 
that pus may be formed by the tubercle bacillus itself; the ordinary 
tuberculous "cold abscess" is not really pus, but merely thick, amor- 
phous, granular debris. 

Extension. — (1) Tubercles develop at the point of infection and 
also in the nearest lymph-glands, which permanently or temporarily 
arrest the process. (2) Infection may occur through the uninjured 
mucosa or skin, but the process rarely passes beyond the tributary 
lymph-glands. (3) The later advance of the process occurs inter- 
ruptedly or gradually, so that it can be traced clearly at autopsy. (4) 
Extension usually occurs along the lymph vessels and glands. 



I. Tuberculosis Miliaris Acuta. 

Definition. — An acute general, sometimes almost universal, embolic 
dissemination of the tubercle bacillus in great numbers, by the blood 
or lymph stream. It results pathologically in the formation of miliary 
tubercles, which are wide-spread in various tissues, and it produces, 
clinically, acute toxaemia, pulmonary, meningitic, or other symptoms, 
and is invariably fatal in a few weeks. 

Etiology. — 1. Development. — Acute miliary tuberculosis always 
develops from a tuberadous focus. This is found in direct ratio to the 
carefulness of dissection; von Buhl, who first fully described the affec- 
tion (1856-1858), recognized that miliary dissemination occurred by 
absorption from old tuberculous foci, just as pyaemia results from 
local suppuration; and he found the primary focus in 90 per cent, of 
cases. It may be small or even microscopic and may easily escape 
detection (Pizzini, Cornet, Spengler), but Simmonds found the initial 
lesion in 100 per cent. As Cornet remarks, it is curious that miliary 
tuberculosis occurs from foci so small as to be easily overlooked, and 
that large tuberculous lesions so seldom result in miliary dissemina- 
tion. A description of all primary foci would be an enumeration of 
every possible localization of tuberculosis. 

2. Lesion. — Pulmonary tuberculosis is the most frequent lesion, and 
causes over 50 per cent. (Ruehle, Orth, Litten) of the cases of acute 
miliary tuberculosis (which occurs in 3 per cent, of the cases of pul 



314 THE SPECIFIC INFECTIONS 

monary tuberculosis). Glandular lesions rank next, and articular, 
osseous, genito-urinary, and serous-membrane tuberculosis, cause 
most of the balance. The more the tubercle is indurated, the less 
is the danger of local or general dissemination. 

3. Mode of Access of Bacilli into Blood Stream. — Sir Astley Cooper, 
in 1798, found tubercles in the thoracic duct, and this was later con- 
firmed by Ponfick, Weigert, Koch, and Meisels. In 1877, Weigert 
demonstrated that tubercles invade the vessel walls, which Rokitansky 
had declared to be immune. Tuberculosis reaching a vessel usually 
causes its gradual obliteration and in this way keeps the process local. 
In some cases bacilli reach the lumen of the vessel and are distributed 
in the direction of its current. Two views are held as to the nature 
of the involvement of the vessels: (a) that of Weigert, who thought 
the most frequent process was periangitis, by which, for instance, 
a caseated gland became adherent to and emptied into a vein; and 
(6) that of Benda, who contended that the common lesion was end- 
angitis, by which tubercle bacilli lodged in the vessel's intima, and, 
grouping there, further disseminated the infection. One of the most 
common methods is periadenitis of a tuberculous bronchial gland, its 
adhesion to a pulmonary vein, and final rupture into it. Tuberculous, 
lesions may rupture into the vena azygos, pulmonary artery, aorta, 
thoracic duct, jugular, thyroid, supra-renal, or renal veins, into the 
cava?, or into the brain sinuses. From the pleurae and peritoneum 
infection may travel directly to the thoracic duct. 

4. Organs Involved. — (a) Rupture into a pulmonary vein floods 
the arterial circulation with bacilli, whence miliary deposits occur in 
the brain, choroid, liver, spleen, kidneys, thymus, thyroid, heart 
(myocardium near pulmonary artery), bones, serous and mucous 
membranes, and in the blood-vessels themselves, (b) Rupture into a 
portal venous radicle affects chiefly the liver, (c) Into the pulmonary 
artery, the lungs, and (d) into a peripheral artery, the tissue supplied 
by it. 

5. Degree of Lesion. — Acute generalization only follows the intro- 
duction of large numbers of bacilli, for they do not multiply in the 
blood. A few bacilli reaching the circulation cause a solitary tubercle 
in some organ — for example, in the brain. Repeated ruptures of 
moderate numbers of bacilli lead to the so-called chronic miliary 
tuberculosis (v. L). 

6. Predisposing Factors. — Though miliary dissemination may occur 
at any age, it is most frequent in children at the developmental period, 
especially between one and four years of age, because the circulation 
is faster, metabolism is quicker, thrombosis of the vessels is less fre- 
quent, tissue reaction is less marked, and the lymph-vessels and spaces 
are wider. Depleting factors, pregnancy, the puerperium, trauma, 
bone operations, measles, pertussis, mixed infections, and the spring 
and summer months, are somewhat predisposing causes. 

Symptoms. — The clinical picture varies greatly, depending on (a) 
the quality (virulence) and quantity of the bacilli; (b) the toxins 



TUBERCULOSIS MILIARIS ACUTA 315 

thrown into the circulation from the primary ruptured focus; (c) 
the toxins developed elsewhere by the bacilli ; and (d) the localization 
of the tubercles formed. Naturally toxemic symptoms precede local 
symptoms. 

1. Temperature. — Continuous fever may be observed in very acute 
cases with wide-spread localization, which do not involve the brain; 
as a rule it is lower than that of typhoid. Remittent or intermittent 
fever is more common; miliary tuberculosis following pulmonary 
phthisis may change neither the hectic fever of the latter nor its eu- 
phoria. The typus inversus may occur, though it usually lasts but a 
few days (Bruniche). In 17.5 per cent, of cases (Rheinhold) the course 
is afebrile; involvement of the brain or meninges lowers the tempera- 
ture or renders it variable; hemorrhages, vomiting, or diarrhoea, may 
depress the fever (Litten) ; low temperatures are common in the aged, 
in the ambulant, and in bronchitic or cardiac types. 

2. Circulation. — (a) The pulse is faster than is proportionate to 
the degree of fever, being 120 in the early stages and 140 to 160 later; 
the blood-pressure is low but dicrotism is infrequent; a pulse under 
100 is very rare and nearly always occurs in old people and in cases 
of meningitic localization, (b) The heart is somewhat dilated and an 
apical systolic murmur, with accentuation of the second pulmonic 
sound, is fairly frequent, (c) A pericardial rub is heard on rare occa- 
sions, and is due to roughening of the serosa by the miliary eruption 
(Litten). (d) Tubercle bacilli were first found at autopsy in the blood 
by Weischselbaum and Meisels, and clinically by Lustig and Rueti- 
meyer, Sticker, Ulacacis, and Doutrelepoint. In the death agony from 
lung tuberculosis, bacilli may enter the blood, (e) The leukocytes 
are usually not increased. 

3. Respiration. — Early symptoms are frequent, (a) There is' very 
often a severe continuous cough, which is always a suspicious symptom. 
It is due to the toxins or to irritation of the vagus twigs by abundant 
miliary nodes in the lung; it causes considerable muscular pain, but 
little voiding of sputum and ceases later if the brain becomes involved. 
(b) The breathing is increased to 40 or 60 in adults, and to 80 or 90 
in children, (c) Dyspnea and cyanosis develop from irritation of the 
vagus (R-uehle) or from diaphragmatic involvement (Rheinhold). The 
tachypncea, dyspnoea, and cyanosis, are peculiarity significant diagnos- 
tically in that they have no adequate explanation in the physical 
findings, (d) The sputum is scant, foamy white, and mucous, in acute 
cases. It seldom contains dots of blood, and is rarely rusty without 
the presence of complicating pneumonia. It may be more abundant 
in subacute cases, (e) The physical findings are not as marked as 
the urgent respiratory symptoms would indicate. A tympanitic note 
is very frequent, resulting from relaxation of the lung, or from acute 
emphysema from coughing. Dulness only results from older tuber- 
culous foci in the lung, or from complicating atelectasis or consolida- 
tion. Auscultation often reveals fine rales, which are especially 
suggestive when they occur over the upper chest, where stasis is 



316 THE SPECIFIC INFECTIONS 

uncommon. Juergensen notes a fine pleural rub, which is due, he 
thinks, to pleural tubercles. A terminal pulmonary oedema is frequent. 
At autopsy innumerable translucent nodes are scattered through the 
lung, and are most apparent on oblique illumination. 

4. Nervous System. — Nervous symptoms may predominate, and 
may result from toxaemia (like the symptoms following tuberculin 
injection), or from central organic changes, (a) The toxsemic symp- 
toms are headache, dulness, vertigo, and tinnitus; these are followed 
by delirium, muscular adynamia and tremor, and result in sopor, 
which is broken by fits of delirium, and finally in coma. In rare 
instances coma may develop early in an apoplectiform fashion, or the 
sensorium may be normal, (b) Meningitic symptoms (see Diseases 
of Meninges) may develop, such as headache, variable pulse and 
respiration, tenderness of the spine with retraction of head and spinal 
rigidity, narrow and then widened pupils, strabismus, paralysis of 
other cranial nerves, Kernig's sign, clonic contractions, convulsions, 
and coma. The findings at autopsy are essentially those of tuber- 
culous meningitis (v. Meningitis). 

5. Digestive System. — The tongue is febrile and there is anorexia. 
Nausea and vomiting are usually meningitic. There is usually con- 
stipation and the abdomen is normal. Diarrhoea is infrequent, but 
bloody stools may occur with tympany and without ulceration (See, 
Rheinhold). Litten once heard a friction rub over the liver. Ascites is 
infrequent in miliary tuberculosis of the peritoneum (as distinguished 
from tuberculous peritonitis). Miliary tubercles may occur in the 
stomach and bowels, mostly in children. 

6. Choroidal Tubercles. — These were first found at autopsy by 
Nanz (1857), Nusch and Cohnheim, and clinically by von Graefe 
(1857) and Leber. They are said to occur in 16 per cent. (Rheinhold), 
22 per cent. (Demme), and 75 per cent. (Litten) of the cases. They 
are most likely to be found when the tuberculosis is very general. 
They occur singly or in large numbers (52, Cohnheim), usually in 
both eyes as whitish-yellow protuberances with irregular washed bor- 
ders. They become quite large, for they cause so much atrophy of 
the retinal pigment layer which covers them that they can be seen 
through it. Daily examination for them is necessary, as they fre- 
quently develop in half a day. They are seen only after one or several 
weeks. (Tubercles of the choroid are depicted in Plate VI, Fig. 6.) 

7. Other Symptoms. — Emaciation is often pronounced; one of 
Wunderlich's cases was reduced to one-quarter of his ordinary weight. 
The spleen is enlarged in 70 per cent. (Litten), but is usually smaller 
than it is in typhoid, except in children, where it may assume great 
dimensions. Collin observed swelling of the lymphatic glands, which 
in one instance became enormous. The urine is concentrated and 
dark, from the fever and from sweating, may contain albumin or pep- 
tone, and quite often shows the diazo reaction. Rosenstein observed 
anuria, especially in children. Hemorrhages into the gums, nose, 
retinae, and intestines, are infrequent and possibly result from mixed 



PLATE VI 







6. Tubercles in choroid. 7. Syphilitic ehoroidoretinitis. 8. Albu- 
minuric retinitis. 9. Hemorrhages in pernicious anaemia. 
(Figures 1 to 3 are from Jaeger and the balance are from Sahli.) 



TUBERCULOSIS MILIARIS ACUTA 317 

infections. The skin is pale and cyanotic; profuse sweats, and there- 
fore sudamina, are frequent. Herpes may be observed, as well as rose 
spots (Waller, Jaccoud, Collin, Senator, Eichhorst, Hager), miliary 
tubercles in the skin (Heller, Meyer, Lichtenstern, Reusberg-Solingen), 
petechia?, erythema nodosum, and terminal oedema. 

Types and Diagnosis. — All the symptoms enumerated are not con- 
stant. Waller (1845) distinguished the following forms: 

1. Typhoid Type. — The febrile onset may be gradual or sudden, 
with or without chills. The status typhosus, delirium, headache, 
moderate continuous or weakly remittent fever, enlarged spleen, bron- 
chitis, less frequently roseolas, meteorism, diarrhoea, and intestinal 
hemorrhage, may cause close resemblance to typhoid (q. v. for differen- 
tiation). Epistaxis is less common ; hyperaesthesia, and herpes, are more 
common but all symptoms may be deceptive except the typhoid bacil- 
laemia and the Widal reaction in typhoid, as opposed to the tubercle 
bacillaemia and choroidal tubercles in miliary tuberculosis. The ty- 
phoid type is due to greater toxaemia with less local reaction from the 
tubercle, and therefore with few local findings. It is more common 
in children than in adults, and runs a course of ten to twenty days, 
or somewhat longer. Typhoid and miliary tuberculosis have rarely 
occurred in the same subject (Birch-Hirschfeld, Burkart, Massini, 
Schuetze, and two personal observations). 

2. Respiratory Type. — This has several forms. Pneumonia may be 
closely simulated by the fever, chills, pain, cough, rusty sputum, in- 
creased breathing, dyspnoea, cyanosis, prostration, or even by tubular 
breathing (in children). Capillary bronchitis (bronchopneumonia) 
should be differentiated after recent measles, or after pertussis with 
patches of atelectasis. Diagnosis should be made from senile bron- 
chitis and emphysema in the aged, in whom this type is particularly 
frequent without fever (Rokitansky held that emphysema excluded 
tuberculosis, but it does not). In the respiratory type the toxaemia 
is rather subordinated by the local miliary eruption. Tachypncea, 
dyspnoea, and cyanosis, without proportionate physical findings are 
always suggestive. Tubercle bacilli in the sputum (or urine) are no 
part of the miliary process, but may occur accidentally. The course 
averages three to four weeks. 

3. Meningeal Type (v. Meningitis). — The symptoms may be, as 
stated above, clearly organic, and yet, in children who are especially 
prone to this form of miliary tuberculosis, toxaemia may very closely 
simulate actual inflammation, as in Henoch's cases, where only brain 
oedema was found instead of the anticipated meningitis. The in- 
creased deep respiration, with occasional deep breathing and increased 
irregular heart action, are suggestive (Ruehle). The choroid findings, 
the results of lumbar puncture, and Kernig's sign, are corroborative. 
Splenic puncture to recover bacilli is never justifiable. Lumbar punc- 
ture often shows the presence of bacilli. 

4. Other Types. — These are less frequent, but their mere mention 
may show the great and almost necessary liability to diagnostic error 



318 THE SPECIFIC INFECTIONS 

in atypical forms. They are: the latent type (Leudet), marked only 
by catarrhal symptoms, and often called grippal; the ambulant type, 
as in Graewitz's case, where an apparently healthy soldier died after 
four days of indisposition; nephritic (Collin); arthritic (Laveran); apo- 
plectiform, delirium tremens (Waller), pharyngeolaryngeal (Catti), 
suffocative (Graves), or asthmatic (Andral) type; fulminant type 
(Denne, Hager), where the patient dies in a few hours, or in his sleep. 
In some cases, sepsis, miliary carcinosis, uraemia, or the cyanosis of 
nitro-benzol poisoning, may be suggested. 

Remissions may occur for a time, even for a month of two, as the tox- 
aemia may subside, while the tubercles continue to develop. The fall of 
the fever resulting from brain implication may be deceptive. Chronic 
miliary tuberculosis is rare. As a rule the course is acute, even 
stormy Or peracute, and death intervenes from exhaustion, menin- 
gitis, heart weakness, dyspnoea, high temperature, hemorrhages, or 
pulmonary oedema. 

Severe infection is fatal in two or three weeks, moderate infection in 
one to two months. Recovery is almost impossible, but Waller, Wun- 
derlich, Burkart and Spengler, believed that it exceptionally occurred. 
Strieker saw recovery of a case in which the diagnosis seemed incontest- 
able, as he found bacilli in the blood. Therapy is useless. The symp- 
toms should be treated expectantly, as they are in typhoid, pneumonia, 
and meningitis. 

II. Tuberculosis of the Lungs (Phthisis, Consumption). 

The lungs are involved with great frequency, not because they are 
peculiarly susceptible, but because infection by inhalation is the most 
frequent cause of tuberculosis. Besides this aerogenous infection, 
secondary infection by the bloodvessels, as in miliary tuberculosis 
(hematogenous infection), and by the lymph vessels (lymphogenous 
infection), is possible. 

Pathology. — The tubercle bacillus localizes in the bronchi (tuber- 
culous lymphangitis), bronchioles or alveoli (tuberculous pneumonia), 
and causes a tubercle like that described in the general pathology. 
There is cellular hyperplasia of the alveolar, epithelial, and endothelial, 
cells, and fibrinous inflammation develops. Isolated tubercles by 
fusion cause the conglomerate tubercle. 

Extension. — (a) Lymphatic extension is the most common form. In 
young individuals the lymph paths are wider and absorption generally 
is greater, so that intoxication and bacillary migration are more active. 
Those who have lost weight, as convalescing typhoids, show greater ab- 
sorbing powers; absorption is also greater after trauma, pneumonia, 
etc. Bacilli may pass the bronchi and reach the glands at the hilum, 
which in turn may infect the blood or break into the lung. Extension 
is usually along the lymph vessels in the bronchial walls (lymphangitis 
tuberculosa), (b) Extension by the air passages is quite common; 
when a tubercle ruptures into the bronchi, its contents may be coughed 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 319 

up or waved upward by the ciliated epithelia if they are not injured; 
on the other hand, a deep breath may aspirate, or coughing may impel, 
infected particles into sound areas, where they develop into new foci; 
much depends on whether the bacilli are living or dead; if living, an 
active tuberculosis develops; if dead, a pneumonia (lobar or lobular) 
is more common, (c) Extension by the bloodvessels may cause a local 
miliary dissemination in the lungs (or in the entire body). Preliminary 
to the clinical description in which special pathological features will be 
fully described, it may be said that some caseated areas fuse into large 
infiltrations; some may encapsulate or calcify and thus effect a tempo- 
rary arrest or a permanent recovery; other caseated areas soften, 
forming ulcers and cavities. 

Symptoms. — A clinical description covering all types is impossible, 
as the course may be galloping, or extremely chronic; one form is 
marked pathologically by caseation, another by ulceration; one symp- 
tom, such as haemoptysis, may indicate the type, and may be the first 
and chief symptom; in some persons the symptoms suggest other dis- 
eases and the physical findings are indeterminate or lacking; in others 
the physical findings are remarkably dissociated from the usual 
symptoms. In the following description, the symptoms and signs 
usually found will be covered first and the special types will be dealt 
with afterward: 

(A). Local Respiratory Symptoms. — These are usually the first noted, 
and may only appear months after the primary focus has begun to 
spread; they are due to the local tubercle and its toxins. 

1. Cough. — Cough is commonly one of the first symptoms; it is 
usually present from the incipiency to the close of phthisis, though it is 
sometimes absent. The cause is that the toxins irritate the vagus 
twigs, which irritation is referred to the medulla, from which issue 
muscular contractions, with the glottis closed in order to evacuate the 
slight secretion; as shown by Nothnagel, Stark, Kohts, and Reyher, 
the interarytenoid space and tracheal bifurcation are the most sensitive 
areas. It is sometimes referable to pleurisy, catarrh of the pharynx, 
enlarged bronchial glands, or laryngitis. It is slight at first, and has no 
peculiar characteristics, other than being dry, difficult and paroxysmal. 
Later it becomes more frequent but less difficult as the secretion in- 
creases. In some cases it is most severe in the morning, the secretion 
having accumulated over night, while in others it is most severe at 
night, for the lungs become congested by the dorsal decubitus; saliva, 
reaching the larynx during the night, may cause a sudden explosive 
cough. It may be provoked by dust, smoke, variations in temperature, 
such as those resulting from opening windows or getting into the cool 
bed, by exertion, laughing, or taking alcohol. It varies with the indi- 
vidual, being more marked in neurotics and less conspicuous in the 
phlegmatic, the aged, or in the insane. When quite obstinate it may 
constantly invoke vomiting and lead to great emaciation. 

2. Sputum. — The sputum is first caused by the toxins, and later by 
the secretion from the tuberculous focus. At first it is glairy and con- 



320 THE SPECIFIC IXFECTIOXS 

tains sago-like bodies which are composed of alveolar cells transformed 
into a myelin substance. It later becomes yellow from admixture of 
pus, or yellow or red from saprophytic organisms, such as sarcinse, or 
the bacillus aureus or squamosus. A green tinge may result from the 
bacillus pyocyaneus or fluorescens. Blood may give it a red, rusty, 
flesh-like, or chocolate hue. It tastes sweet and smells slightly foetid. 
Its amount varies from a few globules to over a pint. It is more abun- 
dant in cavities than it is in extension of tuberculosis by the blood- or 
lymph-vessels; it stagnates before death, because of the patient's mus- 
cular weakness; women and children are prone to swallow the sputum. 
Nummular sputum from cavities is flat, "coin-like," greenish-gray, 
extremely abundant, and sinks in water, as it is airless; it occurs in 
other than tuberculous cavities, as in bronchiectasis. The only char- 
acter istic of the sputum is the tubercle bacillus (v. s.), which is found 
only in tuberculosis; it may be seen before the advent of any physical 
finding, but in other cases it must be sought repeatedly, as it appears 
only when ulceration communicating with a bronchus, develops. The 
tubercle bacillus is found in only one-third of the cases of incipient 
tuberculosis. Other bacteria and saphrophytes are frequent (v. Bac- 
teriology, 8). If the patient expectorates into water a crumbling pre- 
cipitate, rich in bacilli, is obtained (Virchow). Elastic fibers are found 
in 70 to 90 per cent, and originate from the vessels, or from the par- 
enchyma of the lung. The elastic fibers from the vessels are elongated 
and twisted, and sometimes considerable shreds of the vessel-wall are 
seen; the elastic fibers from the bronchi are also long and twining; 
those from the lung substance often show its alveolar arrangement. 
Elastic fibers can often be located by flattening the sputum between 
two plates of glass and picking out the yellowish areas for microscopic 
examination. Treatment with caustic potash, and centrifuging, facil- 
itate their detection when they are scanty. They merely denote a 
destructive process, hence are also found in abscess, gangrene, infarction, 
and in pneumonia. Detritus, pus cells, red cells, alveolar, bronchial 
and buccal epithelium, myelin droplets and pigment, are also found. 
The so-called calculi of the lung are sometimes voided; they are cal- 
cified particles from old areas of caseation, from bronchial obstruction, 
or from peribronchial lymph glands; from the glands large calcarious 
masses may cause fatal obstruction of the trachea, or suffocation may 
be averted only by immediate low tracheotomy. Chemistry : 88 to 98 
per cent, of the sputum is water; 3 to 11 per cent, is organic, and less 
than 1 per cent, is inorganic matter; tyrosin, glycogen, urea, lecithin, 
cholesterin, fatty acids, nuclein, and a pepsin-like ferment, may be 
found. (See Plate VII for tubercle bacilli and elastic fibers). 

3. Hemoptysis. — Haemoptysis (hsemoptoe, spitting of blood) occurs 
in a variable percentage. Prior saw it in 37 per cent, of 1,000 cases; 
others place it at 66, 80, or even 90, per cent. ; it is more frequent in 
adult males than in females and is rare before puberty, (a) Early 
haemoptysis is due to erosion of the mucous membrane, or often erosion 
of a small vessel by tubercles in its perivascular lymph sheath. The 



PLATE VII. 





Tubercle Bacilli and Elastic Fibers. 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 321 

toxins usually prevent extensive early hemorrhage by causing coagu- 
lation in the vessels in and near the affected lung area. Haemoptysis is 
the first symptom in 4 per cent, of phthisis cases and is fairly often 
(16 per cent.) the only symptom, the patient never having future 
trouble; in most cases, however, other symptoms develop; bacilli and 
elastic fibers may be seen at the time of bleeding. Reiche recently cor- 
roborated the old statement that early haemoptysis is not unfavorable. 
The bleeding often occurs without cause, coming on suddenly with a 
warm, salty taste in the mouth and the evacuation of a dram or more of 
bright frothy blood, either clear or mixed with mucus ; small particles of 
darker blood are brought up, for a few days, after which it disappears; 
in 4,125 of the Brompton Hospital cases, 69 per cent, evacuated less 
than half an ounce. In other instances haemoptysis is excited by cough- 
ing, laughing, bathing, exertion, or excitement. Bubbling rales may 
be heard on the side of the lesion, and moulds of the bronchioles may 
be voided. F. Strieker collated 900 cases of haemoptysis in the German 
army among 1,728,505 soldiers, between 1890 and 1895; in 480 cases 
there was no cause, and of these 87 per cent, were tuberculous; of 43 
cases brought on by exertion, 74 per cent, were tuberculous; and of 24 
cases due to trauma, half were tuberculous. The occurrence of early 
hemorrhage, before other symptoms of phthisis, led Hippocrates, 
Boerhaave, Van Swieten, Morton, Graves, Niemeyer, and others, to 
think that haemoptysis caused phthisis, while Laennec, Louis and 
Traube, correctly regarded it as a symptom of already established 
phthisis. The earlier idea is explained by the fact that in bleeding, 
blood and bacilli may be aspirated into other parts, in which the process 
develops anew (v.i. Acute Forms); fever following haemoptysis is 
therefore rather ominous, (b) Late hcemoptysis may be slight or pro- 
fuse. Profuse bleeding is usually due to erosion of bloodvessels running 
across, or in, the walls of cavities, which are frequently aneurysmatic 
(Rasmussen) ; occasionally larger vessels, such as the pulmonary artery, 
are ulcerated. Amounts as large as a pint or a quart may sometimes 
spurt out of the mouth, causing acute anaemia, suffocation, or rapid 
exsanguination. Blood may accumulate in large cavities, never reach- 
ing the air passages. While haemoptysis is usually a sign of 
tuberculosis, it may occur from other causes (v. Diseases of the 
Lungs). 

4. Dyspncea. — This is infrequent, even when the respiratory area 
is enormously contracted, just as it is absent in pleurisy of gradual 
onset; it is often absent even with great infiltration, great cavity for- 
mation, or induration of two-thirds of the respiratory space, whereas 
in sudden miliary tuberculosis the dyspnoea is great. In some cases 
dyspncea is neurotic, or it may follow pressure of swollen glands on 
the vagus, anaemia, stagnating secretion, extensive vicarious emphy- 
sema, or massive pleural adhesions. It is most often due to the rapid 
heart action. In the last stages it may cause orthopnoea and can 
result from intercurrent bronchitis, pneumonia, or pneumothorax. 
Germain See has described a tuberculous pseudoasthma. 

21 



322 



THE SPECIFIC IXFECTIOXS 



5. Pain. — Pain is moderately frequent. Its location may be apical, 
basal, diaphragmatic, or on the anterior part of the chest from the 
clavicle to the third rib or under the scapula. Its character is usually 
sticking and intermittent, but not intense; the skin is often hyper- 
sesthetic to pressure and palpation. Its cause is chiefly acute pleurisy, 
for lung disease causes no pain, and chronic pleurisy is generally pain- 
less; other causes are muscular fatigue from coughing, intercostal 
neuralgia, and less often intercostal neuritis. Pain may be intense in 
pneumothorax. 

(B). General Symptoms. — These result from absorption of the toxins 
secreted in the local lesions. 

1. Fever. — This is present in the great majority of cases and is 
almost invariable in the early stages. Its cause is somewhat disputed; 
probably the dominant factor is the tuberculous toxin, whose febrile 
action is analogous to that of tuberculin; secondary infections un- 
doubtedly may cause fever, though not necessarily, for it is proven 
that the associated streptococci are usually far from virulent. Fever 
marks the tubercle formation, fusion of foci, advance of the disease, 
degeneration of the tubercle, and probably secondary infection; its 
cessation is synchronous with temporary or permanent arrest of the 
disease as manifested by improved health, strength, and weight. Its 
height and course are somewhat influenced by the individual; labile 
individuals possess labile temperature centres (de Renzi); fever can- 
not be classified by the clinical stages, as incipient fever, ulceration 
fever, etc. 

Fig. 20. 



104 


DAY 1 


r, 


3 


4 


5 


6 




„ .A A A 


101 






- / \ / \ / \ / 


1 / \ 


J \l V \ \i \ 


1 \ v \ / V \ 


V \J 



Hectic-fever curve in phthisis. 

Types. — Intermittent fever may exactly resemble malaria and can 
be detected only when registered every two or three hours; remit- 
tent fever most often occurs late in the clinical course; continuous 
fever occurs early or in acute consumption, though it rarely resembles 
the typhoid curve; in some cases the fever falls from high to sub- 
normal registers, sometimes with collapse, which was regarded as 
unfavorable by Ruehle; the typus inversus with morning exacerbation 
and vesperal solution is very uncommon. Fever may be absent in 
cases of old cavities and of fibrous induration. Chills have no relation 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 323 

to the fever nor to its intensity. As fever is indicative of toxaemia, it is 
often associated with anorexia, emaciation, and other symptoms to be 
immediately described. 

2. The Blood. — (a) The red cells rarely number less than 2 million, 
though Limbeck records a case with but 730,000; the anaemia may 
antedate all other symptoms, whence the frequent confusion of chlor- 
anaemia and incipient phthisis. Again, anaemia may be inconspicuous 
or late. In some cases the red cells are increased, notably in individ- 
uals prone to haemoptysis (Mircoli). (b) The haemoglobin may fall to 
25 per cent., but averages 70 to 80 per cent.; it may be decreased 
more than the number of red cells, therein resembling chlorosis (chlor- 
ancemie tuberculeuse). (c) The leukocytes may be normal; again, 
in cavity formation (secondary infection) their number may rise to 
12,000 or 15,000; they are increased in cases of caseous pneumonia 
or protracted pyrexia; after injection of tuberculin the eosinophiles 
show a decided increase, (d) Tubercle bacilli are seldom found in the 
blood except in the death agony. 

3. Sweating. — This is more important than in any other disease. 
It occurs in 90 per cent, of cases (Louis). The most likely cause is 
the action of toxaemia on the sweat-centre in the medulla, though there 
are many other theories. Heavy coverings may sometimes cause 
sweating. It is more frequent in acute than in chronic phthisis and 
in younger than in older subjects. The term " night sweats" is used 
because nearly all of them occur in the night, chiefly between 2 and 
5 a.m. They are most frequent when cavities are forming, and in the 
last stages. They have no constant relation to the fever but are more 
frequent when it is variable. 

4. Pulse. — The pulse is rapid, digestion is frequently disturbed, 
muscular strength is reduced, and nutrition is depreciated {v.i. Com- 
plications, for details). 

(C). Physical Signs — In adults, the apex of an upper lobe, more often 
the right than the left, is first affected (Laennec). The reasons ascribed 
are various, such as a poor apex blood supply, slower lymph current, 
and less expansion, — which are scarcely proven. It is more correctly 
held that coughing drives infection upward from the bronchi, and 
that the clavicle or first rib compresses the bronchi passing to the apex. 
The summit of the apex is not invaded first. Birch-Hirschfeld, in 
early cases which died from causes other than tuberculosis, found that 
in 24 per cent, the disease began in the fourth or fifth order of bronchi 
in the upper lobe and that the posterior were affected earlier than the 
anterior divisions. 

1. Inspection. — (a) The nutrition may be good, but, later, emacia- 
tion is marked. The face is pale, the cheeks hectic, the nose pointed, 
the eyes hollowed and glistening, the neck thin, and the chest is altered 
in various ways; in some cases it is long and narrow, with wide inter- 
spaces, sharp costal angles, prominence of Louis' angle, and more 
vertically directed ribs; in others it is flattened anteroposterior^ and 
the ribs are closely apposed; in still others the funnel-chest may be 



324 THE SPECIFIC INFECTIONS 

seen. Laennec recognized that the ''paralytic chest " was the result 
and not the cause of phthisis. Examining the patient in a good light, 
the following may be noted: (b) deficient expansion above or below 
the clavicles, especially when examined from behind and above; in 
the lower chest, an impaired or absent excursion of the diaphragm 
(Litten's phenomenon). Deficient expansion may be due to pleural 
adhesions, to atelectasis of the lung resulting from caseous nodes 
obstructing the bronchi, to a cavity, or to gradual induration of the 
focus, which is an effort towards encapsulation and recovery, (c) 
Distention of the chest may be due to vicarious emphysema, effusive 
pleurisy or pneumothorax, (d) The cardiac impulse may be increased 
by retraction of the left lung away from the heart. 

2. Palpation. — Palpation shows (a) decreased expansion, elicited by 
standing behind the patient with the thumbs above either clavicle 
and the fingers below it, or by standing in front of the patient and 
applying the spread fingers and hands over the anterolateral parts 
of the thorax; (b) increased vocal fremitus, obtained when the lung 
is infiltrated (caseous foci or pneumonia), indurated or is the seat of 
cavities, all of which increase conduction of the voice-sounds from 
the bronchi. The depth of the focus is a factor, superficial lesions 
showing more clearly than deep ones; thick pleural adhesions or 
plugging of the bronchi with caseous material decrease the fremitus. 
(c) The systolic distention of the pulmonary artery and the second 
pulmonic closure are better felt when the lung retracts from the heart 
or when it is infiltrated in its vicinity. 

3. Percussion. — (a) Incipient infiltration of the apex gives a short 
percussion note, which later becomes dull. According to Grawitz 
the apex is first involved in SS per cent, of cases. Durness is detected 
in the apex or under the middle of the clavicle, at which level Birch- 
Hirschfeld found the anatomical beginning of tuberculosis. The 
apices are best percussed when standing behind the patient, and it 
should be remembered that the right apex is normally less resonant 
than the left. The lung tissue lying behind, or near, the clavicle can 
be well tested by gently tapping the clavicle with one finger. The 
apex reaches 1 to 2 inches above the clavicle, and behind to the ver- 
tebra prominens. Piorry, Friedreich, and Eichhorst, demonstrated that 
impaired resonance is produced only by consolidation measuring ljby 
2\ inches in area and within § inch of the surface, and that foci of 
these dimensions lying deeper than 2 inches escape detection. Oester- 
reich holds that a focus as large as a cherry may cause dulness. Small 
multiple or deep foci give a tympanitic note. To detect slight early 
alterations in note, percussion should be gentle, symmetrical parts 
should be compared and the patient should hold Ins breath in full 
inspiration; the muscles must be relaxed, and it should be recalled 
that each patient has his own percussion note, which varies with the 
individual's muscles, fat, and bones. Often the first dulness of con- 
solidation is found behind, in the supra- or interscapular region. The 
dulness mav extend from the clavicle to the second and third costal 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 325 

cartilages, then to 1.5 inches below the apex of the lower lobe at the 
level of the fifth dorsal vertebra; this area is almost always involved 
when the upper lobe shows distinct consolidation; extension occurs 
outward and downward along the interlobar fissure; then it extends 
to the apex of the upper lobe on the other side. (6) Shrinking, or 
fibrous induration, and a thickened pleura, give apical or other dulness. 
Sometimes the lung becomes vicariously emphysematous about an old 
focus which is thus hidden clinically and pathologically, (c) A tym- 
panitic, or cracked-pot resonance, may be obtained over cavities (v. i.); 
percussion over a cavity sometimes induces sudden evacuation of its 
contents. 

4. Auscultation. — This is the most important aid, next to the micro- 
scopic examination of the sputum, (a) The vesicular murmur, espe- 
cially at the apex, is altered, — for detection of which the patient is best 
examined without deep breathing or coughing; the jerky " cog -wheel" 
breathing may be due to small tubercles in the pleura or bronchi, 
somewhat stenosing their lumina; it is only suggestive and occurs in 
normal individuals; Potain considers.it due to pounding of the heart 
on the lung during inspiration (also a cause for the cardiorespiratory 
systolic whiff, which is heard in the front, sides, and back, of the chest 
during deep inspiration, in healthy as well as tuberculous subjects). 
The breathing may be weak, indeterminate, or "puerile. A rude, rough 
inspiration may be heard, which is due to peribronchial tubercles com- 
pressing the bronchioles. The expiration is frequently prolonged, 
rougher, and higher pitched, in apical " catarrh"; it is long, sharp, and 
bronchial, in older foci. It must be remembered that the breath-sounds 
are physiologically higher pitched on the right than on the left side, 
and that what seems clinically to be catarrh is often consolidation, 
pathologically, (b) Bronchial breathing is caused by various consoli- 
dations (tuberculous, pneumonic, neoplastic, or gangrenous infiltration) 
and by cavities, tuberculous and otherwise. Bronchial breathing of 
moderate degree is physiological in the interscapular region, but is 
considerably less intense than that of consolidation, (c) Rales are 
rather an evidence of infiltration (consolidation) than of "catarrh". If 
they are heard in the apex, the presence of tuberculosis should be sus- 
pected, though they may occasionally occur there physiologically. 
The vibrations of the accessory muscles of respiration, when the patient 
takes a long forcible breath, may be confused with rales, but are easily 
differentiated after a little experience. Rales may not be heard unless 
the patient breathes deeply or coughs, and auscultation should be 
made before, and then after, coughing and deep inspiration. In incip- 
ient consolidation, small crackling crepitant rales are heard over the 
alveoli and smaller bronchioles, at the end of inspiration; they later 
become larger, ringing and resonant, which proves that the alveoli 
and bronchioles have become airless over a considerable area, or that 
softening or formation of cavities is in progress; scattered, clear, 
large, crackling rales are heard over small cavities in the apex or 
in the smaller bronchi, and indicate a viscid secretion. Clicking vales 



326 THE SPECIFIC IXFECTIOXS 

near the heart may occur in the systole, as the heart beats upon an 
adjacent infiltration. In emphysematous patients, whose chests ex- 
hibit sibilant and bubbling rales, auscultation and diagnosis of develop- 
ing tuberculosis may be most difficult, (d) Bronchophony (a bronchial 
quality imparted to the voice-sounds) is heard when the patient counts 
or speaks during auscultation; it indicates infiltration or cavity for- 
mation but is absent when the bronchi are plugged with secretion. 
JE go phony is merely a higher grade of bronchophony and occurs, as 
Skoda demonstrated, in cases of consolidation, in middle-sized cavities, 
and above pleural exudates and transudates, (e) Pleural friction may 
result from rough tubercles in the pleura, or from fibrinous pleurisy. 
(/) A systolic bruit over the subclavian artery is probably due to 
pleural adhesions to the artery. 

5. Roentgen Rays.— The rays show shadows which may be due to 
consolidation, thick-walled cavities, calcified foci, gangrene, pleural 
callus, or pleural exudate. The excursion of the diaphragm can be 
followed; shadows toward the apices, due to the muscles, may be 
readily eliminated, by moving the arms; the results are often confus- 
ing. 

The findings of inspection, palpation, percussion and auscultation 
are grouped together, because they are found together clinically, one 
part showing the signs of consolidation, another those of cavity for- 
mation or of induration. To summarize, (a) the signs of consolidation 
are decreased expansion, increased vocal fremitus, initial tympany fol- 
lowed by dulness, high-pitched expiration, then distinct bronchial 
breathing, crepitant rales and bronchophony; (b) the signs of indura- 
tion are retraction, or lagging behind of the fibrous area on breathing, 
pleural adhesions, increased vocal fremitus, dulness, usually large 
rales, bronchial breathing and bronchophony, (c) The signs of cavity 
formation are: (i) increased vocal fremitus, if it is near the surface; 
(ii) tympanitic note, which may increase in intensity when the cavity 
is percussed with the mouth open (TYintrich's change of note; it is 
also observed in cases of consolidation lying over a bronchus), when it 
is percussed during inspiration (Friedreich's change of note), or when 
it is percussed with the patient in the sitting posture (Gerhardt's 
change); the note may be metallic; the cracked-pot note, Laennec's 
bruit de pot fele, is obtained in cases of superficial cavities measuring 
2h inches with thin walls, which communicate with an open bronchus 
by a small opening; variation in the percussion note from accumula- 
tion (dulness), or emptying of secretion (tympany), is most suggestive 
of cavity formation; (iii) the breathing, which is loudly bronchial, or, 
if the cavity is quite large, is metallic, amphoric or metamorphosing; 
metamorphosing breathing is breathing which begins normally and 
suddenly becomes bronchial (Seitz) ; (iv) bronchophony and segophony ; 
(v) large, resonant rales, which are the most frequent and important 
finding; metallic rales in the apices are most suggestive of cavities; 
they may acquire an amphoric character in very large, thin-walled 
excavations; (vi) nummular sputum; (vii) systolic murmurs, which 



TUBERCULOSIS OF THE LUNGS {PHTHISIS, CONSUMPTION) 327 

are sometimes booming or metallic, and are due to propagation of the 
heart tones; they are occasionally heard at some distance from the 
patient. 

Cavities are due to the breaking down of caseous areas and are 
usually connected with the bronchi. Their evacuation into the bronchi 
is partly favorable, in that the infective material is evacuated; partly 
unfavorable, because it opens up avenues for infection by aspiration. 
They rarely heal by obliteration; they may leave fistulous cicatrices 
(Laennec's cicatrices fistuleuses); if they are held by adhesions the 
cavity remains, contracting cicatrization being impossible; there is 
always danger of their further extension by secondary infection, or 
of gangrene. The cavity has a well-marked limiting membrane, from 
which pus, nummular sputum, elastic fibers, and grayish granular 
detritus composed of masses of tubercle bacilli, are voided; the cavi- 
ties are frequently multilocular, may heal on one side and extend on 
another, and sometimes occupy an entire lobe or even an entire lung. 
They may rupture into the pleura, pericardium, or bloodvessels; in 
one instance the author saw a cavity rupture into the mammary gland, 
resulting in diffuse subcutaneous emphysema. 

Stages of Pulmonary Tuberculosis.— Tuberculosis usually develops 
for six to eighteen months before any symptoms appear. 

1. Phthisis Incipiens. — In incipient phthisis the general and local 
symptoms appear as above described, with fever, anaemia, and rapid 
pulse. The modes of onset are various, for tuberculosis may simulate 
chlorosis, malaria, dyspepsia, laryngitis, or bronchitis, or may appear 
in other forms more directly suggestive of tuberculosis, such as haemo- 
ptysis, pleurisy, or cervical adenitis. The physical findings are uncer- 
tain or absent. 

2. Phthisis Confirmata. — The appearance of distinct physical find- 
ings indicate not incipient phthisis, but confirmed established phthisis. 

3. Phthisis Consummata. — This is advanced consumption, with 
marked hectic fever, cavity formation, and emaciation. 

Course. — The average case of "chronic ulcerative phthisis," with 
the symptoms and signs already described, stands midway between 
the following very acute and extremely chronic groups: 

(^4). Acute, Galloping or Florid Consumption. — This type probably 
always develops from some old focus, such as tuberculosis of the 
bronchial glands, or from a small cavity which by rupture disseminates 
the process; possibly the virulence of the germ is greater in these 
cases; pregnancy, diabetes, alcoholism, measles, whooping-cough, 
influenza, or trauma, may be the immediate cause. 

1. Acute Pneumonic Form. — The acute pneumonic form is acute 
caseous pneumonia. The terms are employed because of the great 
clinical resemblance to, and confusion with, acute lobar pneumonia ; but 
it must be remembered that genuine lobar pneumonia does not caseate, 
and that this form is not synonymous with tuberculosis compli- 
cated by acute pneumococcic pneumonia, which, in this association, 
runs its usual course. Acute caseous pneumonia begins in an indi- 



328 THE SPECIFIC INFECTIONS 

vidual in seemingly perfect health, or perhaps in one whose health is 
somewhat but not suggestively reduced. An initial rigor is fairly com- 
mon, or the spitting of blood may be the first symptom. There may 
be cough, pain in the side, rapid breathing, and sudden fever, which 
are all apparently compatible with a diagnosis of genuine pneumonia. 
The fever, however, is remittent or intermittent, and more variable 
than in lobar pneumonia; dyspnoea and cyanosis are less frequent 
than a gradually increasing pallor; sweating is usually copious. In 
a few days dulness prevails over a lower lobe but much more often 
over an upper lobe or over an entire lung. The breathing, which is 
at first indistinct, may remain so (Traube), but quite often becomes 
bronchial and is associated with crepitant and coarse mucous rales. 
The sputum is often typically pneumonic, viscid and rusty, or again 
is of an olive or grass-green color (Traube). Tubercle bacilli are 
sometimes found, but in this case originate not from the fresh pseudo- 
pneumonic patches, but from the causal focus (the primary cavity). 
In some few cases the physical signs of the primary cavity in an upper 
lobe can be elicited. Albuminuria is uncommon; the diazo reaction 
is nearly always present. The physical findings change but little, 
though the crepitant rales decrease and are replaced by coarse mucous 
rales; the anticipated crisis does not occur, and most cases are still 
called unresolved pneumonia until the increasing anaemia, loss of 
strength or rapid pulse, suggests a tuberculous pneumonia. Of 13 
cases reported by Fraenkel and Troje, 11 died within six weeks, and 
Traube observed a fatal issue in thirteen days. In some few cases 
considerable regression may occur and it is barely possible for connect- 
ive tissue to develop, dragging out the course for three months or 
even for years. The findings at autopsy are most interesting; usually 
an old focus of tuberculosis is found, a ruptured cavity or gland; 
from it caseous material, containing bacilli and tuberculous toxins, 
is aspirated into many finer alveoli and bronchioles, where they set 
up a miliary caseous lobar pneumonia, depending on the size of the 
affected area only. The inflammation is seemingly due wholly to 
Koch's bacillus or its toxins, and is (a) partly fibrinous and desquam- 
ative, red and white polynuclear and mononuclear cells being 
poured out; proliferative changes are noted, as the epithelioid and 
giant cells which are seen in the typical tubercle; caseation ensues, 
as shown in the already fused and fusing yellowish-gray areas; (b) 
the most rapid exudation is serous, Laennec's " gelatinous or smooth 
pneumonia," which is probably due, as Fraenkel and Troje insist, to 
the toxins of the tubercle bacillus and not to mixed infection as Ortner 
and others maintain; this part of the inflammation may regress, and 
does not necessarily caseate. Cavities rarely form in this type. 

2. Acute Disseminated Form. — Acute disseminated tuberculosis, 
sometimes characterized especially by haemoptysis, may occur as a 
special acute type, or may complicate the ordinary form of phthisis. 
Following the rupture of a small centre of softening, which is usually 
located only at the postmortem, and following dissemination by aspira- 



TUBERCULOSIS OF THE LUNGS {PHTHISIS, CONSUMPTION) 329 

tion, there develop fever, repeated haemoptysis, chills perhaps, rapid 
pulse, rapidly increasing dyspnoea, diffuse crepitant or bubbling rales, 
considerable delirium, or even a pronounced status typhosus. Haemo- 
ptysis is absent in some cases. The sputum is absent or scanty, and 
the bacilli are sometimes absent throughout the course. Death may 
occur acutely in three to four weeks without a breaking down of the 
foci, or a remission may take place, after which there is breaking 
down of the indistinct foci which cause slight dulness and distant 
bronchial breathing. At autopsy, scattered, opaque, yellow, partly 
caseous peribronchial nodular foci are seen; in some cases the pres- 
ence of tuberculosis is proven only by microscopic examination, for 
the foci may resemble the ordinary bronchopneumonic patches and 
may present no caseation. Secondary infection with streptococci is 
usually said to cause this form, but Prudden's experiments have 
demonstrated that the above lesions may result from the tubercle 
bacilli alone. 

3. Acute Disseminated Ulcerative Form. — The acute dissemi- 
nated ulcerative type is often observed in children between two and 
six years of age (Grancher), in pregnancy, alcoholism, diabetes, and 
influenza. The foci, which vary from the size of a pea to that of a 
walnut, are widely disseminated; they fuse, break down early, and 
develop cavities without walls, which are only ulcers or consist of 
necrotic caseous material. There are present clinically hectic or 
continuous fever, pronounced anaemia, exhausting sweats, rapid 
emaciation, and viscid sputum, which may be brownish but is more 
often purulent and contains many bacilli; diffuse fine and large rales 
and bronchial breathing may be heard. The course is galloping, and 
ends fatally in one to four months. 

4. Acute Miliary Form. — Acute miliary tuberculosis (q. v.) de- 
velops in 3 per cent, of the cases of pulmonary phthisis. 

(B). Chronic Tuberculosis. — 1. Chronic Ulcerative Form. — The 
ordinary chronic ulcerative phthisis may run a course which is long 
latent, except for anaemia, dyspepsia, or other undistinctive symptoms. 
Improvement may follow the detection of such positive lung findings as 
an apical catarrh, and the cough, fever, sweats, and anorexia, may 
subside; another relapse may occur after quiescence for years, or 
exacerbations may develop, with loss of weight and strength. Recovery 
may occur, even with pronounced physical signs. Cornet regards the 
breaking out after years of new tuberculous manifestations as rein- 
fections rather than relapses. 

2. Phthisis Fibrosa. — Phthisis fibrosa is the slow development of 
fibrous connective tissue excited by the tubercle bacillus. It may 
begin acutely or follow an insidious course from the onset. Its explana- 
tion is difficult; Auclair thinks the bacillus secretes two toxins, one 
with a necrosing action which leads to caseation, and another with 
an indurating action which leads to fibroid phthisis. There may be 
no cough, sputum, fever, emaciation, or anaemia. Bacilli may or may 
not be found in the sputum. Ulceration may result only from mixed 



330 THE SPECIFIC INFECTIONS 

infection. Sometimes there is haemoptysis. It may develop in an 
emphysematous chest (Sokolowski). If left-sided, the spleen rises 
higher and the retraction of the lung away from the heart makes its 
apex wider, the cardiac shock more diffuse, and the pulsation of the 
pulmonary trunk more visible. If right-sided, the liver rises, the right 
ventricle is apparently enlarged (from lung retraction) and is often 
actually hypertrophied and dilated from increased intrapulmonary 
tension. The heart may be drawn to the right or left by the inevitable 
pleural adhesions, bronchiectases are not uncommon, the sound lung 
is vicariously emphysematous, and the diseased lung is smaller, flatter, 
and depresses the shoulder, impairing expansion and often presenting 
bronchial breathing and large rales. 

3. Pleuritic Form. — The pleuritic form (see Pleurisy) follows 
small latent foci in the lungs, lymph glands, and spine. Exudates not 
due to rheumatism, inflammation in contiguous organs, tumor, or 
nephritis, are always suggestive of tuberculous pleurisy. Pleurisy, in 
fact, more often precedes than succeeds pulmonary tuberculosis and 
repeated attacks are frequent, with moderate irregular or continuous 
fever, perhaps with rales in the apex of the affected side (not the rales 
frequently heard just above the upper level of the exudate), or with 
dulness in the contralateral apex. Bowditch, following up 90 cases of 
pleurisy, found that 33 per cent, developed pulmonary tuberculosis later 
in life. 

Variations According to Age.— (A). Children.— Tubercle bacilli 
easily pass the bronchial mucosa and produce tuberculosis of the 
bronchial and mediastinal glands; the wide lymph-vessels and more 
active metabolism have already been noted. In children the process 
in the glands attacks secondarily the hilum of the lung and the lower 
lobes (80 to 98 per cent.). This invasion also explains the frequency 
with which the thoracic duct and bloodvessels are attacked and miliary 
dissemination results. 

1. Chronic Generalized Tuberculosis. — The younger the child 
the less local and the more general is the tuberculosis. Measles, pertussis 
and influenza are very prone to arouse a latent tuberculosis in the 
bronchial glands. The course is generally less chronic than active, 
like that of tumors in children. Emaciation, anaemia, enlargement of 
the spleen and liver, moderate intumescence of such peripheral lymph- 
glands as the cervical, inguinal, and occipital, are observed. Fever 
may occur only toward the end of the process. Hectic fever is seen 
chiefly in children over three years. The sputum is swallowed, but 
washing the stomach recovers bacilli-laden sputum. 

2. Acute Miliary Tuberculosis (v. s.). 

3. Localized Lung Tuberculosis. — Localized lung tuberculosis 
may be (a) of the acute caseous type resembling pathologically bron- 
chopneumonias of other causation, and the microscope may be necessary 
to detect its nature; haemoptysis is rare, though Henoch has observed 
over a dozen cases under six years of age. (b) Chronic localized forms, 
like those of adults, are very infrequent under six or seven years of age. 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 331 

In children, the physical findings are often absent; when present 
they are usually over the lower lobes, very seldom near the clavicles. 
In "half the cases the wrong diagnosis is made (Henoch). Percussion 
is more difficult than in adults, because of the small chest and its 
thinner walls; for example a cracked-pot resonance can be obtained 
in a normal young chest by strong percussion. Children, too, breathe 
irregularly, and puerile respiration is physiological. Induration is rare. 

(B). The Aged. — In the aged, haemoptysis is rare, physical findings 
are less frequent than in adolescence, because the breathing is weaker, 
and emphysema is more common. Cough and fever are also less con- 
spicuous. 

Diagnosis of Pulmonary Tuberculosis. — Early diagnosis is most 
important. A positive family history is of some value, but it does not 
establish the diagnosis in a doubtful case, nor does its absence exclude 
tuberculosis. The Bacillus tuberculosis distinguishes pulmonary tuber- 
culosis (a) from other catarrhs, such as acute and chronic bronchitis, 
or influenza; (b) from other consolidations, pneumonia, broncho- 
pneumonia, actinomycosis, neoplasm, or syphilis; (c) from other 
vomicae, such as the cavities of abscess, gangrene, actinomycosis, 
echinococcus, syphilis, or bronchiectasis; (d) from indurations other 
than tuberculous. Cultures and inoculations may be made in doubtful 
cases. Injection of Koch's tuberculin produces a local exudative reac- 
tion, and after four or five to ten hours, a systemic reaction, which 
is characterized by chill, fever elevation of even 5 degrees, headache, 
general pains, malaise, nausea, sometimes by erythema nodosum, 
an increase of sputum, rales or even a slight area of pulmonary 
dulness; if the first injection of 1 mg. of Koch's older tuberculin is 
negative, a second injection of 2 mg. may be given the following day. 
A reaction generally means that there is a tuberculous focus in the 
body, but not necessarily in the lungs, unless rales develop at the sus- 
pected spot after the injection. In some cases positive reactions have 
been obtained in chlorosis, syphilis, leprosy, cancer, and actinomycosis. 
Whatever the percentage of individuals with latent tuberculosis, it is 
large enough to cause many errors and render it of little clinical 
value; thus, a case with enlarged mediastinal and supraclavicular 
glands, without other physical findings, gave a positive tuberculin reac- 
tion, though the autopsy showed that they were carcinomatous from 
a clinically latent gastric carcinoma, and the reaction came from a 
single tuberculous mediastinal gland which was of no diagnostic signifi- 
cance. In veterinary medicine it is more valuable, leading to a cor- 
rect diagnosis in more than 90 per cent. (Bang) or 9.7 per cent. (Voges). 
The author no longer uses it, for four cases of miliary tuberculosis 
have apparently resulted from its employment. Marmorek has lately 
devised a more rapid method, by which material (tissue or fluid) from 
the suspected case is injected into the peritoneum of a guinea pig, 
followed in twenty minutes by 0.3 c.c. of tuberculin; if the fluid is 
tuberculous, the reaction is obtained. The serum agglutination test 
is again reviewed by Arloing and Courmont (1904) in "400 cases; the 



332 THE SPECIFIC IXFECTIOXS 

bacilli (from homogeneous liquid cultures) produce macroscopic 
agglutination in a few hours; the test was positive in 88 per cent, 
of clearly tuberculous cases, in 73 per cent, of surgical tuberculosis, 
in 27 per cent, of apparently healthy persons, but is apt to fail in 
advanced consumptives. 

Sticker recommended the use of potassium iodide in small doses (gr. 
iij); it congests the lungs at the seat of the lesion, possibly makes the 
auscultation findings clearer, and carries bacilli into the sputum; its 
use is not wholly free from danger. Neurasthenics may develop a 
phthiseophobia, just as they may develop a syphilophobia. 

Pseudotuberculosis. —The Rhizomucor parasiticus (Lucet and Con- 
stantin), the ray fungus, streptothrix (Eppinger), and the aspergillus 
may cause pseudotuberculosis. The form caused by the Aspergillus 
fumigatus is described as a primary lung affection by Dieulafoy, 
Chantemesse, Widal, Renon, Grancher, and Sergent. Many writers 
consider it secondary only. The fungus is composed of mycelia with 
clubbed ends. It stains with thionine and can be grown. The symp- 
toms of streptothricosis are haemoptysis (23 per cent.), fatigue, ano- 
rexia, dry cough, and, later, a greenish purulent sputum. The 
physical findings are those of bronchitis, less often those of slight 
consolidation or cirrhosis of the lung. Ashton and Wright (1905) 
collated 26 cases of streptothricosis pulmonum, of which most had 
symptoms resembling phthisis; over 50 per cent, were unmixed infec- 
tions, and 76 per cent. died. 

Prognosis of Pulmonary Tuberculosis. — Two issues are possible, 
recovery and death. 

1. Recovery. — Autopsies on hospital cases show 25 per cent. (4 to 
50 per cent.) of healed tuberculosis. Many of the recoveries are only 
relative, since Kurlow's inoculations from seemingly latent caseous 
foci into guinea-pigs were positive in 77 per cent.; such foci may be 
aroused by intercurrent disease, though it is the tendency of some 
writers to regard such recurrence as a fresh infection rather than the 
awakening of an old one. Watson observed a clinical course of fifty- 
four vears, and Fagge one of thirtv-five vears. Recoverv is effected 
by encapsulation, scar formation, and the deposit of lime salts. Lie- 
bermeister believes recovery is possible in 50 per cent, of incipient 
cases. The outlook depends on several factors: (a) the hereditary 
vital endowment of the patient; (b) his character, social situation, 
habits and intelligence; (c) whether the localization of the disease is 
single or multiple; (d) secondary or mixed infection; (<?) digestion; 
(/) degree of toxin absorption (fever and emaciation) ; (g) youth, 
diabetes, pregnancy and lactation are unfavorable; and (h) compli- 
cations (v .i.). 

2. Death. — The clinical course is variable, even in chronic cases; 
it averages two years (Bayle, Laennec, Andral), over two and a half 
years (Pollock), three years (Cornet), and seven years ([Williams and 
Dettweiler], though the latter's cases did not include acute forms nor 
cases in children). The process of death is usually peaceful and 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 333 

painless, though at times it comes with dyspnoea (stagnant secre- 
tion), delirium or convulsions. Mechanism of death: (a) heart failure 
is the common cause, associated with oedema, asthenia, anemia, 
and marasmus. Other causes are far less frequent, as (b) pro- 
fuse fatal hsemoptoe; (c) pneumothorax; (d) pulmonary embolism 
(clots or gas); (e) uraemia; (/) meningitis; (g) perforative peritonitis; 
(h) sudden death without adequate pathological findings. In cases 
of sudden death, Arnold, Brissaud, and Toupet, have found in the 
liver large numbers of bacilli, which probably caused an acute intoxi- 
cation, since Mafucci's experiments have demonstrated that the 
injection even of dead bacilli causes rapid marasmus and death. 

Complications. — Tuberculosis in other organs will be considered 
below. 

1. Respiratory. — (a) Tracheitis and bronchitis occur in almost every 
case; and laryngitis in many cases results from the toxins, (b) Dys- 
phagia usually results only from local involvement of the pharynx or 
larynx; swallowing into the larynx is usually the result of paralysis 
of the epiglottic depressors. Hoarseness, dysphonia, and aphonia, al- 
ways suggest laryngeal tuberculosis, but may develop from such other 
causes as syphilis, erosions, or catarrh; from paralysis of the recur- 
rent laryngeal nerve from pressure by lymph glands; from inflamma- 
tion, on the right side by pleural scars, and on the left by large pleural 
effusions; or from thickening at the hilum. (c) Pulmonary gangrene 
may develop in the cavity wall. Lobar pneumonia is not infrequently 
a cause of death, (d) Dry pleurisy is an almost invariable complica- 
tion, and is a conservative process, which lessens the probability of 
pneumothorax. Exudative pleurisy more often develops previously to 
lung phthisis than during its course. In the latter instance it is usually 
serofibrous, and is generally not extensive. Hemorrhagic pleurisy is 
more common in pleural than in pulmonary tuberculosis. Chyliform 
or adipose effusions may occur (see Chylothorax and Chylous 
Ascites); purulent forms result from mixed infection, from cavities, or 
from pneumothorax. Some pleurisies appear to result from toxaemia 
rather than from direct bacterial invasion. Effusions by compression 
sometimes seem to exert a favorable effect on a lesion of the lung. 
Litten thought that their sudden absorption might occasion miliary 
tuberculosis, (e) Pneumothorax is observed in 5 per cent, of the cases 
(Powell, West), and results from rupture of superficial cavities which 
were forming rapidly without a limiting membrane. Perforation occurs 
most frequently between the second and fourth interspaces, and be- 
tween the mammary and axillary lines. Its onset is spontaneous, or 
results from straining, or coughing. Its occurrence is usually marked 
by sudden symptoms, as great dyspnoea, orthopncea, and cyanosis, 
and sudden physical signs, as lying on the side of rupture, sudden 
ectasia, immobility, dislocation of the heart, spleen, or liver, weak 
vocal fremitus, voice sounds and breathing, a tympanitic note, and 
when serum or pus forms, succussion. The onset is occasionally 
gradual and less urgent, so that pneumothorax may be an accidental 



334 THE SPECIFIC INFECTIONS 

finding. Death in a few hours may result, but life may be prolonged 
weeks or months. Infrequently pneumothorax (q. v.) may exert a 
beneficial effect on the lung trouble. 

2. Circulatory. — a | The rapid pulse first appears only after meals 
or exertion, but later becomes permanent. It is probably toxaeniic, 
but may be clue to mechanical pressure of large lymph-glands on the 
vagus, or to compression or inflammation of the vagus from rnedi- 
astinitis, pleurisy or pericarditis. There is a constant and early lower- 
ing of the blood-tension, and the vasomotor instability causes the 
bright-red cheeks. The pulse may be soft and full throughout the 
course. Sometimes a capillary pulse or a centripetal venous pulse is 
observed. (&) A functional, systolic murmur over the pulmonary 
valves is very common. The heart is pale, fatty, flabby, and weak, 
and has been described as atrophied since the time of Laennec, but 
Potain considers that the small heart is merely accommodative to the 
malnutrition and anaemia. Cardiac hypertrophy is due to renal dis- 
ease, pericardial or pleural adhesions, valvular disease, or emphysema. 
Hypertrophy and dilation of the right heart may follow pulmonary 
induration or massive pleural adhesions. Adhesive or effusive peri- 
carditis may result by extension from pleurisy or caseated lymph- 
glands, but may be clue to tuberculosis, pyogenic infection, or to 
toxaemia alone. Endocarditis tuberculosa is very infrequent; tubercle 
bacilli may be deposited in cardiac clots, or in endocarditic excres- 
cences of non-tuberculous origin. They were first found by Kundrat 
and Heller, but Tripier's case of tuberculous endocarditis was the first 
clear one: according to Benda, this endocarditis is due to miliary 
deposits in the intima. and clinically escapes recognition in most cases, 
though it is sometimes suspected on account of a systolic murmur, (c) 
Thro mho- phi eh it is occurs in about 1 percent, of the cases. 

3. Nervous and Muscular. — a) There may be brain anaemia. In 
some instances the mental power may be normal: oftener there is a 
slight mental weakness, irritability, psychical lability, self-concentra- 
tion, lack of endurance, and triviality. Sleep is often disturbed. Con- 
sumptives are usually optimistic, and they may plan for the future on 
the clay of their death Spes phthisicorum): occasionally melancholia 
or mania develops; fever, anaemia, toxaemia, marasmus, and vasomotor 
changes in the brain, such as oedema, may cause terminal aberration 
or paralysis, (b) Neuralgia and hyperaesthesia are not uncommon. 
Multiple neuritis not infrequently results from the toxaemia (Pitres and 
Vaillardi; it may be latent or may cause only slight sensory disturb- 
ance, or it may result in amyotrophy: it may in part explain the 
oedema when it is not due to cardiac weakness or to thrombo-phlebitis. 
(c) The same toxins which reduce the body weight one-half or more, 
result in marked muscular degeneration and atrophy, which causes the 
flat chest, and possibly also the cardiac wasting. The muscular and adi- 
pose wasting is expressed in the terms synonymous with tuberculosis — 
consumption, phthisis, tabes. The muscles are dry, pale, thin, fatty: 
they show transverse rents, separation of the sarcolemma, poor mark- 



TUBERCULOSIS OF THE LUNGS (PHTHISIS, CONSUMPTION) 335 

ings, granular degeneration, some pigmentation, nuclear multiplication 
or hyperplasia of the connective tissue; myositis is described by De- 
lorme and Reverdin. Their wasting and the nervous toxaemia explain 
the asthenia and incapacitation for work, a matter of national eco- 
nomical importance. The muscles are often irritable, show fibrillary 
contractions, and when tapped or pinched show local contraction or 
lumps, known as myoidema, which also results from emaciation in 
other such affections as typhoid or carcinoma. 

4. Digestive. — (a) The tongue may be furred, or red and clean. 
Aphthae are frequently distressing. Excessive redness of the gums is 
a frequent complication, but is also common in other affections. (6) 
Stomach disorder is present in 33 to 66 per cent, of cases; it may be 
the initial symptom of toxaemia, or appear only late in the process. 
The appetite may be unimpaired, and Cornet instances an advanced 
patient who complained that he could only eat four beefsteaks for 
dinner. Anorexia varies in degree and occurrence, being most marked 
toward evening, when the fever is higher, and most frequent in those 
w T ith previous dyspepsia or poor appetite; it is sometimes nervous 
(anorexia nervosa) with normal gastric chemism; again it may be 
due to glands compressing the vagus (Peter, de Mussy). Brieger 
found the chemism normal in 50 per cent, in the incipient stage, in 
33 per cent, in moderately severe, and in but 16 per cent, in severe 
advanced cases. Klemperer thinks that hyperacidity is usual, while 
Marfan considers it exceptional. After eating there may be a sense 
of fullness or even of pain. Nausea, gagging and vomiting may result 
from pharyngitis, coughing, or from forced feeding. In advanced 
cases, nausea and vomiting occur from over-eating, from toxe- 
mic gastric catarrh, swallowing of sputum, weakness of the stomach 
musculature, and deficient secretion; anatomically, the stomach shows 
anaemia, catarrh, fatty degeneration of the glands (36 per cent.), 
interstitial hyperplasia, and sometimes amyloid infiltration (12 per 
cent.) or peptic ulcer. 

(c) Intestines. — Constipation may be caused by gastric hyperacidity. 
Diarrhoea is usually late; it may be caused by the toxin in the blood 
or in swallowed sputum, by intestinal catarrh, toxaemic obliteration of 
the lymph- and bloodvessels in the gut, peptic or duodenal ulcers, 
tuberculous ulcers, amyloid degeneration or amyloid ulceration in the 
gut. Tuberculous ulcers may exist without symptoms or may cause 
colic, tenderness, pain, and diarrhoea; much depends on their loca- 
tion. According to Nothnagel, ulcers in the small gut, caecum and 
ascending colon probably cause diarrhoea only when combined with 
catarrh or amyloid degeneration; ulcers in the lower colon and rec- 
tum almost constantly induce diarrhoea. It may, therefore, occur 
from causes other than ulceration, and ulcers may exist without it. 
Blood, pus, haematin crystals, and tubercle bacilli, may be present. 
but not always. Tubercle bacilli do not necessarily indicate intestinal 
tuberculosis, as they may pass through with the sputum swallowed. 
Anal fistula occurs in 1.3 to 5 per cent, of the cases, (d) The liver is 



336 THE SPECIFIC INFECTIONS 

fatty (in 10 to 15 per cent.); Jonescu (1902) collected 33 cases of cir- 
rhosis cardiotuberculosa (induration from stasis, with tuberculous 
granulations and fatty degeneration). (e) Tuberculous peritonitis 
(v. i.) may occur by (i) lymphogenic infection — e. g., from the pleura 
or pericardium, (ii) from the intestine, (hi) from the genito-urinary 
tract, or (iy) from the blood stream. It occurs in 5 to 15 per cent, of 
pulmonary tuberculosis. Its forms are diffuse exudative, diffuse adhe- 
sive, and tumor-like agglomerations. 

5. Amyloid Degeneration. — This occurs mostly in chronic ulcerative 
phthisis. According to Blum, 80 per cent, of all amyloid degenera- 
tion is due to tuberculosis, and 68 per cent, to pulmonary tubercu- 
losis; it is found in 8.8 per cent, of tuberculous autopsies. The spleen 
is affected in 93 per cent., the kidney in 77 per cent., the liver in 62 
per cent., the intestines in 28 per cent., and the stomach in 12 per cent, 
of cases. 

6. Genito-urinary — Urinary. — The loss of weight causes phosphat- 
uria (calcium and magnesium), increase of nuclein and chlorides (0.5 
tol or even 12 gm.). Moreproteid is excreted than is ingested. Album - 
ose is sometimes present. Albuminuria usually indicates nephritis, am- 
yloidosis, or local tuberculous disease. Acute and chronic parenchym- 
atous nephritis is not infrequently due to long-standing toxaemia. 
Amyloid disease of the kidney produces albuminuria in but 50 per 
cent, of the cases; in amyloid of the kidney, nephritis is also present 
in 75 per cent., and the chronic parenchymatous type in 66 per cent. 
Bacilli are seldom found, unless there are secondary genito-urinary 
deposits. Ehrlich's diazo reaction is very frequently present, and is 
usually of unfavorable import; the converse is not true — i. e., the 
prognosis is not necessarily good if the reaction is absent. 

Sexual. — In some individuals, the sexual desire is more intense, 
particularly in women, though its increase is grossly exaggerated. 
The menses often disappear early, and pregnancy is less apt to occur. 
Pregnancy often temporarily betters the condition of the lungs, but 
a more rapid course is usual after delivery. Hypertrophy of the 
mammary glands, described by Bedor in 1836, occasionally develops, 
particularly in males, but is rather a simple chronic interstitial mas- 
titis than an actual hypertrophy. 

7. Skin. — Cyanosis is not common. Pityriasis versicolor occurs very 
frequently in the tuberculous; it is due to the tinea furfur (Eichstedt). 
Chloasma, desquamation, coarseness of the hair, herpes zoster, lichen 
scrofulosorum, and purpura, are sometimes observed. Clubbing of the 
fingers (the " Hippocratic fingers"), and toes, develops chiefly in chronic 
cases, is largely due to hypertrophy of the soft tissues (see Acromegaly) 
and is not pathognomonic of tuberculosis, for it occurs also in con- 
genital cardiac disease, aneurysm, bronchiectasis, and emphysema. 
Emphysema of the skin is very uncommon; it follows interstitial 
emphysema of the lungs, and results from rupture of the alveoli, 
pneumothorax, or cavities. (Edema results from ansemia, cardiac 
weakness, phlebitis, or neuritis. 



TUBERCULOSIS OF THE LYMPH GLANDS 337 

Treatment of pulmonary tuberculosis is considered later, after de- 
scription of other localizations of the tubercle bacillus. 



III. Tuberculosis of the Lymph Glands. 

Glandular tuberculosis is most frequent in young children, 68 per 
cent, being found in the first ten years of life (Wohlgemuth). It also 
occurs fairly often in adolescence and sometimes even in the aged. 
It is found anatomically in 99 per cent, of tuberculous children (Ster- 
ner and Neureuther), or according to other statistics in 80 to 90 per 
cent.; it is found in 25 per cent. (Mueller) to 50 per cent. (Babes) of 
all autopsies on children. Scrofula is glandular tuberculosis, but it 
presents characteristics different from those of pulmonary infection, 
in explanation of which it is held by Arloing that the virulence of the 
bacilli is less in scrofulous glands; he found that inoculations made 
from infected glands produced local tuberculosis only in rabbits, while 
generalized tuberculosis resulted in the more susceptible guinea pig. 
Others explain it as an infection with very few bacilli. Neither of 
these explanations is wholly adequate, whence the assumption of a 
special glandular tendency to infection; it has been suggested that the 
glands invaded are poorly developed. The skin, mucous membranes, 
and lymph vessels, are physiologically more patent or more permeable 
in the very young, and an increase of this condition or its persistence 
in older children is regarded as an infantilism or embryoism of the 
glands, mucosae, and skin, i. e., a structural tendency toward infec- 
tion. The accessory causes are the same as in pulmonary tuberculosis: 

(a) an hereditary tendency ; (6) poor hygiene, dark, damp dwellings, 
inadequate nutrition and coarse food given to the very young; (c) 
infections, such as pertussis and measles, to a less extent scarlatina, 
diphtheria, variola, or syphilis. 

General Characteristics. — (a) It usually runs an extremely chronic 
course, (b) Recurrence is very frequent, (c) Multiple lesions are 
usual, (d) Glandular involvement is frequently associated with affec- 
tions of the skin (as eczema, scrofuloderma, or lupus), inflammations 
of the mucous membranes (as conjunctivitis, otitis, rhinitis, or bron- 
chitis), and disease of the bones or joints (as coxitis, or Pott's disease). 
This association is frequently known as scrofula, of which some 
authors, as Cornet, distinguish two varieties — (i) the tuberculous and 
(ii) the pyogenic, caused by the staphylococcus or less often by the 
streptococcus. There is much dispute regarding this division, and it 
certainly seems incongruous to unnecessarily associate tuberculous 
lymphadenitis and arthritis with non-tuberculous forms. 

General Anatomy. — (a) Few bacilli may cause but little inflamma- 
tory reaction and little cellular proliferation; regression is possible. 

(b) Conglomerate tubercles form, with the following issues: death of 
the bacillus in the central caseation, softening and external rupture, 
sometimes calcification or extension locally by the lymph stream or 

22 



338 THE SPECIFIC IXFECTIOXS 

generally by the blood current, (c) Hyperplasia with epithelioid pro- 
liferation (Ziegler.) may occur, without caseation or with very late 
caseation; this form results from infection with few bacilli. The 
lymphadenoid tissue is compressed by epithelioid spindle-shaped cells; 
the glands may reach the size of an egg, and their cut section show 
no gross evidence of tubercle, (d) Mixed infection causes rapid casea- 
tion, necrosis, softening, and early rupture; their cut section appears 
" like that of a raw potato but not so moist" (Virchow); the inflammation 
is often not limited to the glands, but causes a periadenitis, whereby 
the glands fuse, a phlegmon results, and generalization of the process 
throughout the body ensues. In the purely pyogenic (non-tuberculous) 
lymphadenitis, the glands may become homogeneous and dry (the 
hyperplastic lymphoma of Virchow), or productive inflammation may 
result in fibrous induration. 

1. Cervical Tuberculous Adenitis. — Infection occurs through the 
nose, eye, scalp, mouth, pharynx, teeth, or ear; the primary atrial 
lesion may leave no mark; or the bacillus may pass through the mucous 
membranes without producing any lesion in them. Writers who de- 
scribe scrofula as a special symptom-complex, distinguish four stages : 
(a) the initial skin or mucous membrane inflammation; (b) the lymph- 
adenitis; (c) involvement of the joints and bones; and (d) various com- 
plications, as amyloid degeneration, or miliary tuberculosis. 

The figures of Balman (first column) and Wohlgemuth (second 
column) show the following localizations : 

Per cent. Per cent. ' 

Cervical and occipital glands, 81 93 

Axillary (from the mamma), 6 2.78 

Inguinal (from the hip. ilium, testicle, and 

knee), 7 0.93 

Cubital (from the fingers) 5 0.23 

Popliteal (from the foot), 0.7 0.23 

Pre- and postauricular, 2 . 9 

The cervical glands thus make 96 per cent, of Wohlgemuth' s 
series. In cervical scrofula, the glands at the angle of the jaw 
and beneath or anterior to the sternomastoid muscle are most often 
involved; in bilateral involvement, the glands of one side are 
usually larger. The glandular swelling is slow in onset, intermittent 
in progression, is usually unattended by pain or other symptoms, and 
is frequently an accidental finding. In some cases the first symptoms 
are acute, but the trouble subsides in two or three weeks. The intumes- 
cence is first confined to glands which are discrete and freely movable. 
Later the nodes may blend into large nodular masses, and periadenitis 
may fuse the glands and cause their adherence to the skin, which be- 
comes cedematous, dough-like, and reddened. Softening and fluctua- 
tion are then frequent, with burrowing of the pus in various directions 
and external rupture through small fistula?. The fistula? widen, dis- 
charge cheesy and milkv material, and form ulcers covered with granula- 
tion tissue and difficult to heal. Cicatrization leaves deep, deforming, 
depressed scars. Extension may occur to the deeper glands or to the 



TUBERCULOSIS OF THE LYMPH GLANDS 339 

subpectoral or axillary glands. Fever, anaemia, and other toxaemic 
manifestations, may develop, as in lung tuberculosis. 

2. Bronchial Glands. — The bronchial glands are very frequently 
diseased. In autopsies on tuberculous children they are almost in- 
variably affected (in 98 per cent, of Steiner's and Neureuther's and in 
100 per cent, of Northrup's series); in adults they are affected in 40 
to 80 per cent. In children tuberculosis of the bronchial glands is 
primary, the bacillus passing the patent intact bronchial mucosae, and 
tuberculosis of the lung is secondary. In adults lung involvement is 
usually primary and bronchial adenitis is secondary. Small tubercu- 
lous foci cause neither glandular enlargement nor symptoms. Biedert, 
in 1,346 autopsies on tuberculous children, found the lungs diseased 
in 80 per cent., the bronchial glands in 78 per cent., the intestines in 
32 per cent., and the mesenteric glands alone in 40 per cent. 

Symptoms, — In most cases no symptoms develop; in others, pri- 
mary or secondary pulmonary lesions overshadow the symptoms of 
bronchial involvement; in others, miliary tuberculosis develops, pro- 
moted by the close contact of the bronchial glands with, and easy rup- 
ture into, the pulmonary vessels ; in still others, symptoms result from 
the pressure of the glands on the nerves, vessels, or air tubes in the 
mediastinum; in very few cases are there actual physical findings. 

Pressure Symptoms. — Pressure on the vagus, known to Wrisberg, 
causes the rapid heart which occurs so frequently in tuberculous chil- 
dren ; paroxysmal asthma, dyspnoea, or spasmodic cough which some- 
times closely resembles that of whooping-cough; lessening of the 
sensitivity of the bronchi, which favors infection; and it finally leads 
to cardiac dilatation and death. Pressure on the recurrent laryngeal 
nerve is marked by hoarseness, aphonia, dyspnoea, or laryngospasm. 
The air passages, trachea, or bronchi, may be compressed. This may 
be marked by dyspnoea, impaired expansion of one or both sides of 
the chest, and holding the head backward. The pupils may be unequal 
from pressure on the sympathetic nerve. Other pressure symptoms 
are : hypertrophy of the heart or the paradoxical pulse, from pressure 
on the aorta; oedema and cyanosis of the face and arms, from compres- 
sion of the superior vena cava; cough, rales, or haemoptysis, from sten- 
osis of the pulmonary veins; a murmur over the innominate vein on 
throwing the head backward; dysphagia, from oesophageal compres- 
sion. 

Signs. — Bronchial breathing is occasionally heard between the 
second and fourth dorsal vertebrae, more clearly behind than in front ; 
more on the right than on the left side; and more markedly than the 
high-pitched breathing heard physiologically over this region. If the 
bronchus is compressed there is neither bronchial breathing nor in- 
creased vocal fremitus. An irregularly outlined dulness is elicited 
on exceptional occasions either between the clavicle and third rib, 
on either side of the sternum, or behind between the third and fifth 
dorsal vertebrae. It is due to enlarged glands near a bronchus, or some- 
times to a distended obstructed vein. Sometimes a tympanitic note 



340 THE SPECIFIC INFECTIONS 

in the upper lobes results from relaxation of the lung. Both the symp- 
toms and signs are extremely variable, appearing suddenly and remit- 
ting unaccountably. 

Issues. — (a) Tuberculosis of the lung (in children); (b) miliary 
tuberculosis; (c) tuberculous pleurisy or pericarditis; (d) pressure by 
calcification or fibrosis; (e) adhesion to and rupture into the air pas- 
sages, causing sudden suffocation; (/) fatal hemorrhage into the air 
tubes, which is less frequent, as the vessels yield before pressure, but 
which may result from rupture simultaneously into a bronchus and a 
vessel; (g) rupture into the oesophagus or traction upon it, causing an 
oesophageal diverticulum. 

Diagnosis. — As Henoch puts it, "A diagnosis can rarely be made 
(from the physical signs), but if made is nearly always correct," as the 
bronchial glands are nearly always enlarged in infantile tuberculosis. 

3. Mesenteric Glands. — The bacilli pass the patent intact intestinal 
mucosa and settle in the mesenteric glands, precisely as they pass the 
bronchial mucosa and lodge in the bronchial glands. Carriere found 
that but 1 per cent, of his cases were primary; of the secondary cases, 
the primary focus was in the peritoneum in 40 per cent., in the lungs 
in 30 per cent., in the intestines in 20 per cent., in other glands and 
bones each in 5 per cent. There are few characteristic symptoms. 
The glands may be palpable as thick nodular masses through a thin 
abdominal wall, but are often obscured by the abdominal distention. 
The general emaciation (tabes mesaraica) contrasts strikingly with 
the tumid belly. Digestive disturbance is most frequent, and there 
is usually a diarrhoea with thin, stinking stools. Compression is less 
frequent in the more distensible abdomen than in the less yielding 
thorax, though the veins of the abdomen may stand out and oedema 
of the legs may appear. The glands sometimes heal by induration 
and calcification, or, by softening, rupture into the intestine or peri- 
toneum (plastic or exudative peritonitis). Amyloid degeneration may 
result from cases of long standing. 

4. Generalized Lymphadenitis. — This may closely resemble Hodg- 
kins's disease, as was first pointed out by Richard Paltauf and his 
co-worker, Sternberg, though the latter goes too far in declaring that 
most cases of pseudoleukaemia are glandular tuberculosis. In two per- 
sonally observed instances of supposedly clear pseudoleuksemia, the 
clinical and gross pathological findings were typical of that disease, and 
only the epithelioid hyperplasia and the bacilli tuberculosis stamped 
them as tuberculous. This form is rather common in the negro. 

The treatment of tuberculous lymphadenitis is that of tuberculosis 
in general (v. i.), and is surgical if the process is accessible and local- 
ized. In 175 cases of cervical adenitis which were operated on, 58 
per cent, were cured after three years, 8 per cent, had recurrence, 11 
per cent, developed pulmonary tuberculosis, and 23 per cent. died. 
In another series of about 700 cases which were treated medically, 28 
per cent, developed tuberculosis in some other organ (Demme). The 
syrup of the iodide of iron and cod-liver oil are very largely used. In- 



TUBERCULOSIS OF THE SEROUS MEMBRANES 341 

unctions of green soap, recommended by Richter (1846) and Kap- 
pesser (1878) are considered beneficial by Hoffa; 5 ss_ j should be 
thoroughly rubbed into the back two or three times a week. 

IV. Tuberculosis of the Serous Membranes. 

These membranes may be involved simultaneously or separately. 
Multiple serous involvement is known as multiple serositis or polyor- 
rhomenitis. Multiple serositis may be acute, subchronic, or chronic; it 
may be serous, fibrinous, or purulent; it may occur with or without 
lymphadenitis or visceral tuberculosis. 

(A). Pleura. — Tuberculous pleurisy has been touched upon as a 
complication of phthisis, and must be separately considered under 
Pleurisy (q. v.). It may develop as an apparently primary infection, 
it may be clearly secondary to unmistakable phthisis, or it may appear 
as a terminal infection. Miliary tubercles in the pleura may occur 
without coincident pleurisy. Pleurisy develops in some form in 66 to 
100 per cent, of pulmonary phthisis. It may be acute, subacute, or 
chronic; it is most often serous or serofibrinous; it may be serohem- 
orrhagic, purulent, less often chyliform or adipose. Pleurisy may result 
from direct bacillary invasion from the bronchial glands, lung, spine, or 
peritoneum, or possibly from simple toxic action without the presence 
of bacilli. In some cases the pleura proliferates and forms a thick, 
massive, adhesive, obliterative membrane. Sometimes the interstitial 
tissue of the lung is invaded, resulting in pulmonary cirrhosis (pleurog- 
enous cirrhosis). The symptoms are those of fibrinous, effusive or 
adhesive pleurisy (q. v.). 

(B). Pericardium. — Miliary tubercles may in rare cases cause tuber- 
culous pericarditis; these accidental miliary deposits must be sharply 
distinguished from tuberculous pericarditis wherein inflammation pre- 
dominates. It is less common than pleural and peritoneal involve- 
ment, but is not a rare pathological finding. It is found in 2 to 3 per 
cent, of pulmonary tuberculosis. Tubercles may be detected beneath 
the fibrin deposits or adhesions, as they are in pleurisy of the same 
type. Without association with some other tuberculous lesion (espe- 
cially that of the pleura) it is rarely separable clinically from the 
ordinary forms of pericarditis. Like these forms it may be symptomati- 
cally latent, it may form an unessential part of a generalized tubercu- 
losis, or it may present the ordinary symptoms of pericardial effusion 
or concretion (q. v.). Only eight primary cases are recorded (Scagliosi, 
1904). 

(0). Peritoneum. — Tuberculosis of the peritoneum was known to 
Bayle, Laennec, Bichat, and others, a century ago, but became 
especially important when Louis, in 1825, declared that nearly all 
chronic peritonitis was tuberculous. Though some chronic periton- 
itides are due to trauma, alcoholism, nephritis, portal and cava- 
stasis, most of them are tuberculous. 



342 THE SPECIFIC INFECTIONS 

Frequency. — It complicates 9 to 13 per cent, of pulmonary tubercu- 
losis and according to Grawitz and Brunn, it was found in 2 per cent, 
of 13,422 autopsies. According to Cummins it constitutes one-quarter 
of all kinds of peritonitis. 

Age. — It is almost equally frequent in the second, third, fourth, and 
fifth decades, ranging close to 20 per cent, in each; 66 per cent, of 
all cases occur between ten and forty years of age; in the very young 
and the very aged it is infrequent. 

Sex. — Ninety per cent. (Nothnagel), or 78 per cent, according to 
Konig, occurs in women. More cases are found in autopsies on 
males, though more women are operated on. In America it is more 
common among the negroes than among the whites. It is very seldom 
(0.7 per cent.) primary, but is secondary to (a) lung or pleural tuber- 
culosis (in 80 per cent., Leube); (b) intestinal ulcers or mesenteric 
and retroperitoneal adenitis, especially in children. Tubercle bacilli 
may pass the intestinal wall without localizing in it and may reach the 
peritoneum. It is thought by some that intestinal lesions are the most 
frequent cause; (c) tuberculosis of the Fallopian tubes, which some 
consider causative of a third, or half, of the cases; tubal tuberculosis, 
however, is usually secondary to some small focus in the bronchial 
glands. Infection by contiguity and by the lymph-stream is said to 
be far more common than hematogenous infection, although the 
writer believes that tuberculous peritonitis is hematogenous. 

Tuberculous peritonitis is a frequent complication of liver cirrhosis, 
as pointed out by Rokitansky, Foerster, and Weigert, though it seems 
strange that tuberculosis should develop in any stasis. It also compli- 
cates ovarian tumors. In some instances it follows trauma, which 
probably disseminates infection from a preexisting quiescent focus. 
Occasionally it is found in a hernial sac (tuberculosis herniosa), of 
which 62 cases are reported (1903). 

Types. — A clinical description is impossible, for the disease may be 
acute, subacute or chronic, latent or stormy, circumscribed or diffuse; 
it may be marked by adhesions, by free or encapsulated ascites, or by 
large tumor-like masses; it may be obscured by coincident miliary 
tuberculosis, liver cirrhosis, exudative pleurisy, or ulcerative phthisis, or 
may appear as a seemingly primary clinical. fact. Though the forms 
are similar and atypical cases are common, certain types may be de- 
scribed. The unessential forms of miliary tubercle, and the small 
and usually non-inflammatory tubercles seen over intestinal ulcers or 
in chronic phthisis, are not taken into clinical consideration. 

1. The acute form usually begins with severe symptoms, which 
include fever, rapid pulse, abdominal tenderness and pain, free fluid 
in the peritoneal sac, which shifts with change of position, considerable 
meteorism from paresis of the gut, vomiting, sometimes diarrhoea or 
at other times constipation. This type may resemble typhoid when 
the intoxication is more marked than the local signs. On the other 
hand, cases occur which simulate internal strangulation and ileus, 
which at times actually results from intestinal adhesions or incar- 



TUBERCULOSIS OF THE SEROUS MEMBRANES 343 

ceration beneath bands. The writer has seen three cases precipitated 
by delivery and for this reason resembling a puerperal infection. Indi- 
canuria, so frequent in other acute peritonitides, is usually absent. 
The ascitic fluid is usually lemon-colored, serous or slightly flocculent, 
and generally of a specific gravity of over 1,014; red blood-cells some- 
times impart to it a hemorrhagic hue; the leukocytes are usually 
mononuclear. In rare instances the acute peritonitis is suppurative, 
and is due to perforation of a tuberculous ulcer in the gut. In some 
cases the acute type is a terminal infection. Though it is commonly 
diffuse, there is sometimes acute local pain or circumscribed effusion, 
which may occur, for instance, over an intestinal ulcer. Plastic adhe- 
sions occasionally tend to modify the freedom with which this ascitic 
form shifts with alteration of posture. Acute tuberculous peritonitis 
comes more often under the care of the physician than of the gynae- 
cologist or surgeon. 

2. Subacute or chronic forms present more or less diffuse peritoneal 
involvement, (a) The fibrino-plastic form, causing adhesions, may 
result from the acute form or may develop slowly and insidiously; 
symptoms and signs are usually lacking, or when present are not dis- 
tinctive, (b) The fibrino-caseous form is characterized by the develop- 
ment of tubercles, which by fusion often form large pigmented solid 
masses. There are adhesions, and thickening of the intestine, mesen- 
tery, and omentum. Between the recesses formed by the inter-intes- 
tinal adhesions, or by the growth of the gut to the liver or spleen, 
pockets of exudate frequently occur, containing blood-stained serum, 
cold abscesses, or cheesy material; the intestine is thickened and con- 
tracted, the mesentery deformed, and the omentum shrunken, (c) 
The effusive form is marked by serous, serofibrinous, serohemorrhagic, 
and less often by puriform or adipose exudate, which is more or less 
encapsulated. 

All these types and subtypes vary so much that the individual 
symptoms will be considered separately. 

Individual Symptoms — 1. Adhesions and Retraction. — The infil- 
trated omentum gradually indurates and retracts so that it is found 
above the navel (Bamberger) or along either costal arch as a fibro- 
caseous tumor-like mass; it may often be palpated, even when there 
is much exudate, and becomes clearer after paracentesis; it may be 
mistaken for carcinoma of the stomach, enlarged liver, or distended 
gall-bladder, especially when in chronic forms there is no temperature ; 
it may also occur in simple or carcinomatous chronic peritonitis, but 
is quite suggestive of tuberculosis. The ivalls of the gut are fre- 
quently so thickened that intestinal stenosis and longitudinal short- 
ening result; the gut may measure but one-half or one-third of its 
original length; it may be thickened, adherent, surrounded by exudate, 
and may also resemble a tumor. Adhesions may continue to retract 
until the entire peritoneal sac is deformed (Kleb's peritonitis defor- 
mans) ; this is a species of spontaneous recovery but is attended by 
danger of intestinal stenosis. The mesenteric thickening and retrac- 



344 THE SPECIFIC INFECTIONS 

tion {mes enteritis retrahens) affects the character of the physical find- 
ings and the tympany and the dulness; the mesentery may measure 
one-half to one inch (1 to 2 cm.) in thickness. 

2. Ascites; Exudate. — The abdomen is often moderately enlarged, 
which is due to serous exudation and meteorism; in some cases inspec- 
tion reveals no objective change. Large exudates may cause some 
distention of the abdominal veins, as in ascites (q. v.), because the 
cava is compressed. When the abdomen protrudes, its centre is not 
usually flattened nor are its sides bulging as in the ordinary ascites 
of liver or cardiac disease (Bouilly), but it is often prominent in the 
median line, as in ovarian cyst. Lohlein states that most of his 
cases were sent to him with a diagnosis of ovarian tumor or cyst. In 
cases without adhesions the dulness shifts easily with change of pos- 
ture, so that tympany exists over the supernatant gut and dulness 
is found over the settling fluid. The physical signs, however, differ 
from those of a common ascites in that the tympany is often on the 
right side; Thomeyer pointed out that the mes enteritis retrahens pulls 
over the small gut to the right side, and that its chief cause is tubercu- 
lous (less often carcinomatous or simple) peritonitis; though this dis- 
position of the tympany is common, nevertheless, a tuberculous mass 
may develop anywhere, as for instance, in the. right iliac region, in 
which case it dislocates the tympanitic intestines to the left, or in the 
median line or in the pelvis. In general the abdominal distention is 
asymmetrical rather than symmetrical; it is generally less extensive 
than, for instance, is liver cirrhosis, with which it may co-exist. In 
very rare cases the fluid may break through, into the bowel or exter- 
nally through the navel. Dulness does not always indicate the presence 
of fluid but may result from close adhesions, from thickening of the 
gut, from caseous masses or enlarged glands. 

3. Meteorism. — -This may result from sudden paresis of the gut 
in the acute type, or from chronic fibrous obstruction in cases of long 
standing. Tuberculous tumors may also impair peristalsis and thus 
cause gaseous accumulations. Meteorism is one of the stigmata of 
tuberculosis of the mesentery glands (tabes or phthisis mesaraica) and 
then is often due to coincident peritonitis; in both conditions, but 
most often in children (Berggriin and Katz), the stools may appear 
uncolored and fatty. 

4. Palpation. — A doughy sensation is often experienced on palpa- 
tion, which is usually referred to peritoneal adhesions or constricted 
intestine, but in some instances is due to early infiltration of the pre- 
peritoneal (subserous) tissues. 

5. Friction Sounds. — In some cases the Beatty-Bright friction-rub can 
be elicited. 

6. Pelvic Effusion. — This is particularly common in women, who also 
suffer from painful and disturbed menstruation. 

7. Temperature. — Temperature frequently occurs, but is irregular 
in character; it is sometimes continuous, even typhoidal, and some- 
times remittent, or hectic; it is most frequent in acute types or in 



TUBERCULOSIS OF THE SEROUS MEMBRANES 345 

acute exacerbations of chronic cases. In some chronic cases it is ab- 
sent or subnormal. The disease therefore cannot be excluded by the 
absence of temperature. Fever, with pain and tenderness, usually, but 
not always, distinguishes tuberculous encapsulation from simple ascites. 

8. Pain and Tenderness. — These are generally conspicuous, though 
moderate in degree and by no means constant. 

9. Marasmus — Emaciation is common and has been especially 
emphasized by Vierordt; Konig, however, remarks upon the frequency 
with which cases of tuberculous peritonitis present a good color and 
robust appearance. 

10. Gastro-intestinal Disturbances. — Digestive disorders are fairly 
frequent; the usual constipation is occasioned by impaired peristalsis; 
in some cases diarrhoea, amounting to 3 or 4 movements daily, is pos- 
sibly caused by toxaemia. 

11. Other Symptoms. — The spleen may be enlarged, but is difficult 
to find in the majority of cases. In rare instances there are icterus, 
pylethrombosis, and other complications due to special localizations of 
the process. 

Diagnosis. — The diagnosis is usually made correctly, though some- 
times there are no just grounds for even suspecting the presence of 
the disease. Considerable importance should be attached to tuber- 
culous lesions elsewhere, as in the lungs, pleurae, glands, or Fallopian 
tubes. Multiple serositis is extremely suggestive. If another tuber- 
culous lesion cannot be established, tuberculous peritonitis, which 
causes nearly all chronic peritonitides, is very probably present; malig- 
nancy and traumatism must be considered. Tuberculin injections 
may be given but do not prove that the lesion is peritoneal or tuber- 
culous. Inoculation may be made with fluid withdrawn by paracentesis 
(see Pleurisy). Exploratory laparotomy is justifiable, particularly 
as simple abdominal section is the foremost therapeutic measure. 

Course. — The onset is usually insidious with marked but not extreme 
pain, tenderness, anorexia, vomiting, colic, fever, and constipation or 
diarrhoea. The course, independent of all therapeutic measures, shows 
spontaneous remissions, as Vierordt and Nothnagel have particularly 
insisted. 

Treatment. — Simple rest in bed, good hygiene, and full feeding, 
very often arrest the process. The tumors, exudate, and adhesions, 
may recede and no symptom reappear for months or even years. 
Spontaneous recovery was first described by Bamberger but was 
ignored until relatively recent times. In 1884 Konig proved what 
Spencer Wells had observed twenty years earlier, that healing may 
follow laparotomy (Czerny, Hegar, Chrobak, Bumm, Israel). Tuber- 
cles may heal entirely in six or seven weeks. Then Lindner, Phillips, 
Valenta, Roersch, Hinterberger, and others, showed that recovery was 
frequent (in 25 per cent, of the cases) without either medication or 
laparotomy. Experimental researches have shown that the tubercles 
heal by simple degeneration, or by vascularization and development 
of connective tissue. 



346 THE SPECIFIC IXFECTIOXS 

Operation gives various results, recovery occurring in 33 per cent. 
(Frees), oo per cent. (Chrobak), 64 per cent. (Konig), 91 per cent. 
(Dohrn) and 94 per cent. (Mazzoni). Larger numbers of cases give 
equally high percentages; 70 per cent., Roersch, 358 cases; 85 per 
cent., Margarucci, 250 cases; von Krenecki, 266 cases, 72 per cent, 
recoveries in ascitic, 62 per cent, in adhesive, and 75 per cent, in en- 
cysted forms; 75 per cent, in 405 cases, Adossides. If the primary 
focus is accessible, as in tuberculous tubes, it should be removed, 
thereby raising the percentage of recoveries from 71 to 97 per cent. 
(Mayo). Simple paracentesis is much inferior to laparotomy. Lavage 
is superfluous. It is thought that the access of air or sunlight, or 
manipulation or lavage, is the potent curative factor in operative treat- 
ment. Veit advances the plausible theory that the withdrawal of fluid 
allows the access of fresh serum with increased antitoxic properties. 
Operation, in the author's opinion, is clearly of great value; but it 
may be mentioned that some conservative writers believe that the 
tubercles which heal after operation were already in process of healing 
spontaneously. 



V. Tuberculosis of the Brain and Meninges. 

Involvement may result from (a) the miliary tubercle, (b) the soli- 
tary, or, as Virchow prefers to call it, the conglomerate tubercle, (c) 
the tuberculous abscess, and (d) meningitis, acute or chronic. The 
miliary form has already been described; the solitary or conglomerate 
tubercle produces symptoms identical with those of brain tumor 
(q.v.), and tuberculous meningitis will be described with other menin- 
gitides (v. Meninges). 

Primary cerebral tuberculosis is extremely rare. Warfringe, Fraen- 
kel, Alvarez and Duerck have described primary meningitis, but it is 
extremely probable that small or microscopic foci elsewhere escaped 
detection. Fraenkel found tuberculous meningitis in 4.7 per cent, of 
adults dying with pulmonary phthisis. 



VI. Tuberculosis of the Alimentary Tract. 

1. Lips. — The lips are very seldom affected; lupus or tuberculous 
ulcers may invade them. The latter are very painful and may be 
confused with cancer or chancre. 

2. Gums. — The gums are seldom involved, though tuberculosis has 
followed caries or extraction of the teeth. 

3. Tongue. — This is involved in 1 to 2 per cent, of cases. Tuber- 
culous tumors may develop in its substance. They are sometimes 
mistaken for gumma or cancer, and may break down into cold ab- 
scesses. Tuberculous ulcers develop on the dorsum or edges; they 
have rough caseous bases with uneven or undermined edges; they 



TUBERCULOSIS OF THE ALIMENTARY TRACT 347 

are almost never primary; they are differentiated from syphilitic ulcers 
by the inefficiency of mercury and iodides, from cancer by the absence 
of glands in the neck, and from both by the presence of bacilli and the 
results of inoculation. 

4. Pharynx. — Pharyngeal involvement was known to Morgagni but 
was especially studied by Ricord (1865). Primary disease is most 
infrequent, and involvement secondary to pulmonary or laryngeal 
phthisis is more common, but still is infrequent; Heller saw but 4 
instances in 8,000 throat cases; Kidd found 6 cases in 500 tuberculous 
autopsies. The process begins largely in the lymphoid structures, 
which are infected by tuberculous sputum or food, or it extends by 
the lymph-vessels from the larynx. Three-fifths of the cases (Marti- 
neaux) are associated with tuberculous disease of the intestine, and 15 
per cent. (Barth) with oral tuberculosis. It is promoted by syphilis, 
by the use of alcohol and tobacco, by trauma, and by preexisting 
ulceration. The cervical glands may be affected in acute, but rarely 
in chronic, cases. The ulcerations are usually superficial ; when pro- 
pagated from the larynx, the most distressing dysphagia results. Retro- 
pharyngeal abscess (Read, Lindenbaum, Northrup) usually results 
from suppuration of the lymph glands and from spinal or osseous 
disease. 

5. Palate. — The palate is said to be affected in 1 per cent, of cases 
of phthisis; in swallowing or coughing, tubercle bacilli from the sputum 
come in close or even forcible contact with the palate. Lublinski ob- 
served three instances among 16,000 throat cases, and Kidd saw 4 
cases in 500 tuberculous autopsies. 

6. Tonsils. — The tonsils are diseased in 4 per cent, of cases of 
pulmonary tuberculosis (Warthin); their folds and crypts contain 
bacilli; the process may stop at the tonsils, for they act as barriers to 
the infection or a tuberculous cervical adenitis may develop. Their 
infection may be primary, and Dieulafoy holds that tonsillar infection 
may be followed by a descending tuberculous adenitis, which in turn 
infects the lungs. Some maintain that the tonsils are almost invariably 
infected by the sputum in phthisis of the lungs; Schlenker finds them 
tuberculous in 65 percent., Krueckmann in 48 per cent., and Dmo- 
chowski in 100 per cent, of his cases of pulmonary phthisis. The 
lesions are miliary more often than caseous. 

7. Salivary Glands.— These are fairly, but not absolutely, immune. 

8. (Esophagus. — The oesophagus is also relatively immune and is 
infected less frequently even than the throat. No clear primary case 
is recorded, and Cone could collect only 48 secondary cases. (Esoph- 
ageal trauma, cancer, or ulceration, tends to localize the bacillus. 
Infection by contiguity, from the peribronchial glands, is more com- 
mon than infection by tuberculous sputum; these glands may occasion 
oesophageal perforation, hemorrhage, diverticula, or stenosis. Exten- 
sion from the larynx or pharynx along the lymph tracts in the sub- 
mucosa, or from the spine or lung cavities, is possible. Miliary 
deposits have no clinical importance. 



348 THE SPECIFIC IXFECTIOXS 

9. Stomach. — The stomach almost never shows primary ulceration. 
There are only four cases on record in which the smallest claim for 
primary involvement can be made. Secondary disease in pulmonary 
tuberculosis is estimated at four-tenths of one per cent, to 2 per cent. 
Letorey, in 1895, collected 21 cases of tuberculous ulcer, but they are 
more frequent than statistics show. Ricard and Chevrier assert that 
there are on record sixteen cases of tuberculous stenosis of the pylorus. 
Klebs's idea that gastric localization was promoted by round ulcer 
is not generally accepted. The HC1 is inimical to gastric tubercle. 
Tuberculous ulceration of the stomach occurs from the sputum, from 
invasion by contiguity (glands, peritoneum, or colon), or in few cases 
from hematogenous infection. 

10. Intestinal Tuberculosis.— This was first observed by Bayle, 
(1810). (a) It is usually secondary to lung tuberculosis with cavity 
formation, and results from infective sputum; its frequency is 30 
per cent. (Eichhorst), 34 to 38 per cent. (Leroux and Mueller, in chil- 
dren), 51 per cent. (Heinze), or 90 per cent. (YYeigert, Orth, Warthin). 
Tubercle bacilli may be swallowed without causing intestinal tuber- 
culosis. Of all kinds of intestinal ulceration, tuberculous ulcers are 
the most frequent. Infection in some cases may occur from the peri- 
toneum or mesenteric glands, but adhesions often render the deter- 
mination of the primary focus impossible. Hematogenous infection 
is barely possible, (b) Primary intestinal tuberculosis is much more 
rare, occurring in but 0.3 per cent. (Eisenhardt), and in only 0.1 per 
cent, of the cases in adults. The intestinal mucosa in children is like 
the bronchial, as it often allows of the passage of tubercle bacilli 
through it to the intestinal glands without disease of the intestine itself; 
this is due to the loose infantile mucosa and the large lymph vessels. 
Kingston, in 339 autopsies on children with tuberculosis, found its 
atrium was respiratory in 64 per cent., intestinal in 19 per cent., 
and uncertain in 17 per cent. Infection may occur by infected milk 
or meat. Koch takes an extreme view in denying infection by milk, 
and Behring takes the opposite extreme in affirming that it is the 
chief cause of tuberculosis. 

The ulcers are most frequent in (i) the ileo-c&cal region and next in 
the colon, (ii) They always originate in the lymphadenoid follicles 
or Peyer's patches and never in the mucous membrane; they are pro- 
moted by erosions or obstipation. Small tubercles fuse into large 
ones, which caseate and ulcerate; in exceptional cases the caseous 
nodes do not rupture but cause the peritoneum and mucosa to bulge 
out. (iii) The ulcers are irregular in shape, and (iv) their disposition 
is ring-like; i.e., they are located transversely around the gut, because 
extension occurs by the lymph vessels (lymphangitis tuberculosa). 
Occasionally they lie in the long axis of the gut and are ovoid, corre- 
sponding, though often incompletely, to Peyer's patches, (v) They 
are single or multiple, and sometimes cover nearly all the surface of 
both the large and small intestines, (vi) Their bases are rough or 
caseous and their edges infiltrated; the infiltration also invades the 



TUBERCULOSIS OF THE ALIMENTARY TRACT 349 

contiguous mucosa and submucosa. (vii) Localized adhesive peri- 
tonitis is a common issue when the process reaches the serosa. An 
early stage of this is seen in the serous and subserous miliary tubercles 
and in the bead-like tuberculous lymphangitis; perforation occurs in 5 
to 10 per cent, of the cases, but is resisted by the muscular coat and 
by adhesions; it results in pericecal abscess and in suppurative peri- 
tonitis. Stenosis of the intestine, single or less often multiple (129 
cases collected by Arbuson, 1904), may also result; recovery is very 
rare. Konig in two years saw 5 cases recover, and Eisenhardt saw 10 
complete and 26 incomplete instances in 567 tuberculous ulcerations. 
Hepatic suppuration or steatosis, may result. 

Symptoms. — The symptoms are those of any form of intestinal 
ulceration {q. v.); they commence usually with signs of catarrhal 
enteritis, diarrhoea, pains, and fever. They may for a while resemble 
those of typhoid. The only pathognomonic finding is the tubercle 
bacillus, and it is possible that its presence may result only from swal- 
lowed sputum. Rosenblatt's method of detecting the bacilli in the 
fseces is to give laudanum until the stools become hard, and then ex- 
amine the mucus on their surface; the bacilli are usually found on 
the first examination, for the hard fseces apparently scrape the bacilli 
from the ulcers. Pus is often found and hemorrhage occasionally 
results. Girode called attention to the black stools, which are usually 
ominous, as they indicate malnutrition; the picture of dysentery is 
rarely observed. Fatal hemorrhage is infrequent, though cases have 
been recorded by Vallin, Hanot, Osier, Chandeze and others. An 
appendicitic form may be noted, with quick or insidious onset and with 
some induration; recurrence is frequent and fistulse occasionally 
develop. In typhlitis tuberculosa there is great thickening in the caecal 
region, with a hard, slightly movable or totally adherent, vertically 
disposed, tender tumor. The onset is usually insidious, pain is recur- 
rent, symptoms of increasing intestinal stenosis are present and con- 
stipation alternates with diarrhoea. Hemorrhage is infrequent, fever 
is usually absent and emaciation is sometimes pronounced. Duguet 
described this condition in 1869, and, since it so fully resembles cancer 
or sarcoma, it has attracted the especial attention of the surgeons, 
Bassini (1887), Bouilly (1889), and Billroth (1891). Campiche (1906) 
collected 379 cases of tuberculosis of the appendix and caecum; about 
25 per cent, of the operated cases died from the operation; about 
35 per cent, were well for months or years; and about 40 per cent, 
ultimately died of tuberculosis. It sometimes co-exists with cancer. 
The process usually begins in the mucosa and is marked by ulcera- 
tion, villosities in the mucosa, great local infiltration and hypertrophy 
of the bowel, and destruction of the ileocecal valve. The process 
may begin, as shown by Conrath, in the serosa, with which tuberculous 
glands may come in contact. Patients may die of acute obstruction. 
or only after a chronic course of a decade or more; recovery by fibrosis 
is possible. Benoit and Dieulafoy regard the process as primary in 
80 per cent, of subjects. 



350 THE SPECIFIC IXFECTIOXS 

In the rectum, ulcers, either anal or rectal, lupus, tuberculosis cutis 
verrucosa, and periproctal abscess, are sometimes seen. Fistula in ano 
occurs in 1 to 5 per cent, of cases of phthisis, and rarely develops in 
other conditions; the general idea that its excision excites pulmonary 
disease is a confusion of cause with effect. 

11. Liver. — The liver is involved less in adults than in children 
(38 per cent. Leroux), but at all ages it is of greater pathological than 
clinical interest, (i) Large tubercles may develop in the liver, some- 
times with peritonitis and perihepatitis, (ii) Miliary tubercles are of 
no clinical significance, (iii) Hanot maintains that there is a pri- 
mary cirrhosis of the liver, associated with tubercles and fatty degen- 
eration; at the most it is extremely rare; it is said to be associated 
sometimes with tuberculous peritonitis and perihepatitis (v. s. Tuber- 
culosis OF THE LUXGS: COMPLICATIONS). 

12. Spleen. — The spleen is involved in 43 to 47 per cent, of tuber- 
culous children (Leroux and Mueller). Bayer (1904) collected 28 
cases of primary tuberculosis of the spleen; 19 were not recognized 
clinically ; 9 were operated on, of which 2 died and 7 recovered. (See 
Diseases of Spleen: Splenomegaly with Cyanosis.) 



VII. Tuberculosis of the Genito-urinary Tract. 

Genito-urinary tuberculosis was described by Morgagni and by 
Bayle in the beginning of the last century, but for the first time fully 
by Lichtheim, in the cadaver, and by Rosenstein, Babes, and Smith, 
clinically. It is most frequent in the period of greatest sexual activity 
(twentieth to fortieth year), and 72 per cent, occur in males, in whom 
the two tracts have more continuity and community of surface. 

Modes of Infection. — 1. Hematogenic Infection. — This is the most 
frequent variety. It occurs in 5 per cent, of cases of chronic pulmon- 
ary tuberculosis. The majority (76 per cent.) of cases are secondary 
to some lung or peribronchial glandular focus, which very often has 
produced no symptoms, so that most seemingly primary foci are 
really secondary. Jani found tubercle bacilli in perfectly sound testes 
and prostate glands, but they were clearly an invasion of the blood 
occurring in the death agony. 

2. Urogenic Infection. — The general opinion was previously that 
a secondary infection mounted from the lower genital to the higher 
uropoietic structures. It may be conveyed by infected fingers, instru- 
ments, or catheters. Infection by sexual intercourse is possible but 
has been grossly overrated. It may follow syphilis and gonorrhoea. 

3. Infection from the Peritoneum and Contiguous Structures. — The 
Fallopian tubes are diseased in a third to a half of the cases of tubercu- 
lous peritonitis. Jani found tubercle bacilli in the tubes in women 
dying of phthisis. The bladder, seminal vesicles, and vasa deferentia, 
may be invaded per contiguitatem from peritoneal, vertebral, rectal, 
and other foci. In many cases it is impossible to determine where 



TUBERCULOSIS OF THE GENITO-URINARY TRACT 351 

the process began, for extension may have occurred so rapidly and 
diffusely. 

(A). Renal Tuberculosis. — The kidney in miliary tuberculosis is 
involved in 90 per cent. (Frerichs), but is marked by no distinguish- 
ing symptoms. Caseous nodes develop in the cortex, infection reach- 
ing it most often (in 90 per cent.) from the blood stream (desquamative 
caseous nephritis); they often break down into cavities, and may 
form cold abscesses or undergo secondary pyogenic infection, or the 
process may remain localized in one pole of the kidney. Tubercles 
also develop, in the apices of the pyramids and pelvis of the kidney, 
and form caseous infiltration and ulcers; involvement in this form 
was at one time considered the result of an ascending infection, though 
Caspar and Walker oppose this view; some maintain that infection 
from below may pass through the bladder (without causing lesions in 
it) and reach the kidneys, just as the bacilli may pass the lungs or 
intestine and cause bronchial or mesenteric adenopathies. Israel and 
others, on the contrary, believe that the process often (41 per cent, 
of cases) descends from the kidney to the bladder. Wherever the 
process begins, upward and downward extension in the kidney itself 
often occurs, so that the entire organ may be more or less diseased. 
When the process is well developed there is a tuberculous pyonephrosis. 
The entire kidney may become a large sac of caseous material, detritus, 
and lime salts; this is called degenerescence massive by Tuffier. The 
kidney is often adherent to adjacent structures; its capsule is thick- 
ened, its removal strips off particles of renal substance, and it is some- 
times perforated, causing tuberculous paranephritis. The surface of 
the kidney may be smooth and normal, lumpy from caseous deposits, 
or softened in many places from diffuse ulceration. In exceptional 
cases spontaneous healing is possible. Whether one or both kidneys are 
diseased depends on the stage of the process, and is a most important 
matter when surgical interference is considered. Israel, in his cele- 
brated observations, stated that he found one kidney involved usually 
without any other genito-urinary disease. Pallet and Albarran ob- 
served unilateral disease in 80 to 85 per cent, of their cases, while post- 
mortem figures show unilateral renal disease in but 48 per cent.; 
naturally, in autopsy figures, the extent of the disease is greater than in 
clinical figures. Compensatory hypertrophy of the sound kidney is 
frequent. 

Symptoms. — These may be absent if the renal pelvis remains sound. 
Otherwise the symptoms are (1) urinary, (2) local, and (3) general. 

1. Urinary. — The urinary symptoms are chiefly those of pyelitis 
(q. v.). The urine is acid, though alkalinity develops in complicating 
tuberculous or non-tuberculous cystitis, which may be determined by 
the cystoscope. Urination is of ten difficult (dysuria) or frequent (polliak- 
uria), so that the existence of cystitis is at first suspected; it is a safe 
rule always to consider the possibility of renal phthisis in every cystitis 
the origin of which is not entirely clear and the treatment of which 
is unsuccessful. Bladder symptoms are reflex or are due to compli- 



352 THE SPECIFIC INFECTIONS 

eating cystitis, simple or tuberculous. The urine is sometimes in- 
creased: Guy on describes an early polyuria in which the urine is 
clear, and a later polyuria in which it is turbid. Hoematuri 
is frequent: it may be severe or slight and its occurrence is more often 
early than late; its frequent recurrence is so marked in some cases as 
to justify the term "hemorrhagic type": it may last one and a half 
months Routier to four and a half years Tuffier . Pyuria generally 
occurs when the pelvis is invaded, but is not observed when cortical 
foci do not communicate with the pelvis nor when the ureter is oc- 
cluded; the pus cells correspond to the amount of albumin. Epithe- 
lial cells, sometimes caseous matter, elastic fibers, and necrotic renal 
tissue, are found. The sediment is often a crumbly, rapidly settling 
detritus: tubercle bacilli are often found, but must not be confused 
with the smegma bacillus u. General Bacteriology : sometimes 
bacilli in the urine are found in pulmonary tuberculosis without any 
disease of the kidneys. Casts are very infrequent. In unilateral renal 
disease with occlusion of the corresponding ureter, the urine is 
naturally normal. Urinary segregation or ureteral catherization deter- 
mines which kidney is involved. 

2. Local. — Local symptoms are lumbar pain and tumor. Lumbar 
■pain sometimes results from capsular tension: it is severe, colicky 
and is reflected to the groins and testes, which may be retracted as 
they are in renal colic: this is probably due to the passage of caseous 
particles or blood clots: differentiation from calculous disease ■:. v. 
may be difficult in such cases until tubercle bacilli are found. Tumor, 
in tuberculous pyonephrosis or hydronephrosis, is a small, tender en- 
largement, though seldom of the size attained in calculous or other 
obstructive disease. 

3. General. — General symptoms are hectic fever, malnutrition, 
tuberculosis in the lungs, and foci in the testes. The heart is almost 
never hypertrophied. In 60 per cent, of the cases operated on, the 
diagnosis was found correct. The course is chronic, with remissions: 
two or three, or even five, years is the usual duration: recovery from 
circumscribed lesions is possible; death results from tuberculous 
generalization, less often from sepsis, perinephritis, or amyloid de- 
generation, and rarely from nephritis or urtemia. The treatment is 
surgical. In Kronlein's cases, the operative mortality of nephrectomy 
was 5.S per cent, and the ultimate mortality was 17.6 per cent. ; 70 per 
cent, was cured. Caspar claims that, since the introduction of 
ureteral catheterization and functional renal tests, the mortality has 
fallen to 7.7 per cent. This is denied by Israel. In Albanian's series 
the operative mortality was 3 per cent. 

B . Ureter and Bladder. — The ureter is thickened, infiltrated, 
caseous, ulcerated, and often stenosed: it is involved in SO per cent, 
of cases of renal tuberculosis Palet and may cause various adhesions, 
such as to the peritoneum. Secondary involvement from the kidney 
may be limited to the ureter at its vesical ending or may spread more 
widelv over the mucosa of the bladder. 



TUBERCULOSIS OF THE GENITO-URINARY TRACT 353 

Bladder disease is rarely primary; secondary disease results per 
contiguitatem or from hematogenous deposits, as can be seen by 
means of the cystoscope. Israel (v.s.) noted tuberculous cystitis in 
41 per cent, of cases of renal tuberculosis, and Vignernon in 50 per 
cent. Cystitis of long standing should always excite suspicion of tuber- 
culosis, even when it has gonorrhceal or other antecedents. Medical 
measures are only palliative. Surgical intervention is indicated. 

(C). Male Genitalia. — The epididymis is more often involved than 
the testis, except in youth, when the epididymis and tunica albuginea 
are more frequently affected; in the first years of life testicular disease 
results from generalized tuberculosis; about one-half of Jullien's cases 
occurred under two years of age. Some hold that these cases are con- 
genital, though the weight of evidence is against this view. Sometimes 
no caseation results, as is the case in the hyperplastic lymphadenitis, 
and even microscopic confusion with sarcoma is possible unless the 
bacilli are especially looked for. Testicular tuberculosis is most often 
confused with syphilis (q. v.), though in the latter there is less pain 
and fever and more nodular enlargement. The seminal vesicles, vasa 
def erentia and urethra may be invaded and a rectal examination 
should never be neglected. Recently the prostate, "the cross road 
of the urinary and genital tracts," has attracted especial attention; 
its primary involvement (Lancereaux) is disputed by some, but the 
gland is affected in 50 to 80 per cent, of the cases of genital tuberculosis 
in the male. The lungs are invaded in primary genital tuberculosis 
in 70 per cent, and the urinary tract in 56 per cent. Treatment is sur- 
gical. Medical measures are usually unavailing. 

(D). Female Genitalia. — The female genitalia become tuberculous 
in 1.5 to 2.5 per cent, of the cases of pulmonary tuberculosis. Infec- 
tion is secondary in over 80 per cent. Tuberculous tubes are found 
in 1.5 per cent, of abdominal operations; according to W. Williams, 
8 per cent, of the tubes removed for inflammatory lesions were found 
tuberculous. Probably nearly all cases are due to some small focus 
in the bronchial glands. The tubes show nodules, infiltration, caseation 
and ulceration; bilateral involvement is usual, and its true nature 
may be apparent only under the microscope; tuberculous salpingitis 
may simulate tuberculous peritonitis; tubal disease may be found in 
very young children. The uterus ranks next and is, as a rule, involved 
secondarily; systematic microscopic examination would doubtless 
show higher percentages than those usually given. Ovarian phthisis 
is almost always secondary. Tuberculosis of the vagina, cervix, vulva, 
and female urethra, are very exceptional. 

Mammae. — The mammae are occasionally diseased; Schley (1903) 
collected 65 cases of which 12 were primary. Carcinoma may be 
closely simulated, for tuberculous lesions occur at the same age, often 
cause nipple retraction and tumor formation, or involve the axillary 
glands (66 per cent, of the cases). When cold abscesses, fistuhe, or 
ulcers form, the diagnosis is naturally more definite. A chronic inter- 
stitial non-tuberculous mastitis was described by Bedor. 

23 



354 THE SPECIFIC INFECTIONS 



VIII. Tuberculosis of the Upper Respiratory Tract. 

(A). Nose. — The nose is seldom affected, because its irritation 
excites lachrymation, sneezing, and increased secretion, which is inim- 
ical to the development of tubercle bacilli. Nasal localization was first 
described by Willigk (1853). In the rare primary form there are very 
few bacilli and there is an exuberant non-caseous growth, which may 
somewhat resemble sarcoma; the absence of caseation is not unique 
because it is sometimes seen in lymphadenopathies and in the Fal- 
lopian tubes; there is little pain and the chief symptom is a chronic 
coryza. In the secondary form the bacilli are abundant; multiple 
caseation and ulceration occur as in other localizations; suppressed 
coughing, with the mouth closed, is thought to force germs into the 
nose. Nasal infection may occur by picking the nose, and is promoted 
by foreign bodies, wounds and ulcers, and by stagnation of the secre- 
tion by various obstructive processes. Infection may spread by the 
lymph vessels, especially in children, to the cervical glands or even 
to the meninges. Lupus (in 33 per cent.) affects the nose (Bender). 

(B). Nasopharynx. — Its primary involvement is infrequent. Second- 
ary disease usually develops late in phthisis and occurs in 20 per cent. ; 
it is promoted by coughing with the lips closed. It may extend by 
contiguity from the pharynx. The third tonsil may be affected (Ler- 
moyez); adenoids are tuberculous in 20 per cent. (Dieulafoy) or in 
27 per cent. (Moure and Brindel). 

(C). Ear. — Tuberculous otitis media occurs chiefly in late phthisis 
(according to Fraenkel in 32 per cent.); otitis may occur from mixed 
infection. It is promoted by measles and scarlatina, is rarely primary, 
and often causes cervical lymphadenitis. 

(JD). Larynx. — Laryngeal phthisis is very rarely primary, though 
some well established cases are recorded. Louis, in 1825, held that it 
was secondary to lung disease resulting from infection by sputum, 
which view still holds; hematogenous and lymphogenous infection 
is rare. Laryngeal tuberculosis develops in 20 to 30 per cent, of cases 
of pulmonary tuberculosis in adults; it develops in only 3 per cent, 
of pulmonary phthisis in children (Parrot). It complicates 9 per cent, 
of lupus cases. Promoting factors are inflammation, fissure, and syph- 
ilis. In 700 cases Krieg observed unilateral involvement in 275 (39 
per cent.), of which 92 per cent, occurred on the same side as the 
lung lesion; Kreig attributed this to lymphatic extension; Cornet 
refers it to paresis of the vocal cord on the affected side, (which is due 
to compression or neuritis of the recurrent laryngeal nerve), and to 
stagnation of the sputum in various recesses on the paralyzed and 
anaesthetic side. Unilateral disease usually becomes bilateral from 
contact. 

Symptoms. — The cough varies with the time of onset of laryngeal 
symptoms; in those rare and unfavorable cases in which the trouble 
begins with laryngeal symptoms, the cough is often somewhat dry, 



TUBERCULOSIS OF THE UPPER RESPIRATORY TRACT 355 

brassy, or metallic; it may come on in the form of acute laryngitis. 
In cases clearly following lung disease, the ordinary bronchitic hack 
frequently becomes brassy; in the last stages it becomes incomplete, 
ineffectual, or like an eructation (Trousseau), as the vocal cords can- 
not come in apposition. Tickling in the larynx is common. Pain 
and hoarseness are followed by dysphonia (or, later, aphonia), dyspnaa, 
and the most painful and distressing dysphagia. 

Forms. — (a) The most common form is the ulcerative; ulcers are 
found in the interarytenoid region, vocal cords, posterior wall of the 
larynx, arytenoids, and epiglottis; they are not deep but are broad; 
their edges are ragged or "nibbled," and, on their rather pale and 
sometimes caseous bases, papillary excrescences are fairly frequent. 
Particles may be inhaled into the lungs, causing tuberculous or sup- 
purative foci. They are to be distinguished from syphilitic ulcers (q. v,), 
which are more often single and are redder, have more "cut out" 
edges, frequently show cicatrization, involve oftener the parts nearer 
the pharynx (epiglottis and posterior surface of the arytenoids), and 
less often attack the vocal cords; show no tubercle bacilli, do not 
show local reaction on tuberculin injection and do respond to mercury 
and iodides. Ninety per cent, of all laryngeal necrosis is tuberculous. 
Perichondritis may occasion sudden cedema glottidis, urgent dyspnoea 
and early death unless timely tracheotomy is performed, (b) In other 
cases the submucous tissues are infiltrated and the mucosa is thick- 
ened or sometimes hardened (pachydermous form); the true cords 
are less involved than other parts; stenosis rarely occurs, and if 
ulceration develops it is inconspicuous, (c) Caseous tumors are not 
frequent; they may precede the ulcerative form or occur independ- 
ently of it. (d) The vegetative type occurs with ulceration, and small 
excrescences develop on the floor of the ulcers, or without ulceration, 
in which case they appear on the otherwise intact mucosa, (e) The 
miliary form is of no essential importance, as the deposits can rarely 
be seen and their symptoms are obscured by the pulmonary or cere- 
bral manifestations. 

Treatment. — Treatment is unsatisfactory, as pronounced lung 
changes already exist and dysphagia occasions rapid emaciation and 
disinclination to eat. Besides general measures (v.i.), local measures 
may be employed, but as a rule they do not essentially modify the 
process. Insufflations of boric acid, iodoform, or iodol, and painting 
with 10 per cent, menthol, 10 per cent, carbolic acid or 20 per cent, 
lactic acid solution (gradually increased in strength to 80 per cent.), 
may relieve the local pain; gr. \ of morphine hypodermically and 10 
per cent, solution of cocaine locally, allow the patient to eat, for a 
time at least, but finally fail to anaesthetize the widespread ulceration. 
The patient may be able to draw up milk and water by a tube, when 
the head is turned over the edge of the bed. Caustics, such as silver 
nitrate, do more harm than good. 



356 THE SPECIFIC INFECTIONS 



IX. Tuberculosis of the Heart and Vessels. 

(a) Pericardium: (v. Serous Membranes). (6) Myocardium: miliary 
tubercles are occasionally seen; tuberculous fibrous myocarditis is 
quite rare; .caseous nodes are very uncommon and occur chiefly in 
the young; Anders in 1902 collected but 72 cases, (c) Endocardium: 
Weichselbaum, Birch-Hirschfeld, Klebs, Kotlar, and Chiari, have 
found tubercle bacilli in cardiac thrombi; Heller, Kundrat, Tripier, 
Londe, Petit, and Courmont, found them in endocarditic vegetations; 
Hanot holds that toxins cause the excrescences in which the bacilli are 
later deposited; Norris found endocarditis in only 1.4 per cent, of over 
11,000 phthisical necropsies; tuberculous endocarditis is almost 
always vegetative and very rarely ulcerative or caseous; secondary 
infection is the cause of some cases of endocarditis which complicate 
tuberculosis, (d) Involvement of the vessels has been described under 
miliary tuberculosis. Primary disease of the vessels seems highly 
improbable, though some few cases are reported; 18 cases of tubercu- 
losis of the aorta are mentioned in the literature collected by Simmitsky . 

X. Tuberculosis of the Bones and Joints. 

This topic properly belongs to surgery, but its relations to glandular, 
pulmonary, and other lesions demand some consideration. Koch was 
the first to demonstrate the almost invariably tuberculous nature of 
caries, fungus joint lesions, and tumor albus, and Damsch first deter- 
mined this relation by inoculations. Schuchart, Krause, Demme and 
Renke proved that spina ventosa was usually tuberculosis. Konig and 
Orth found that about 80 per cent, of bone and joint tuberculosis 
was clearly secondary to pulmonary, glandular, genito-urinary, and 
other tuberculosis. Probably all cases are secondary to tuberculosis 
elsewhere. Infection is hematogenic in the majority of cases, far less 
often lymphogenic. Trauma has long been considered an important 
etiological factor, and experimentation shows that it may determine 
localization in animals already infected with the Bacillus tuberculosis. 
This factor has probably been overestimated, and Sprengel even main- 
tains that the joints oftenest involved are those least subject to trau- 
matism. Thirty-three per cent, of the cases occur in the first decade 
of life, and 50 per cent, in the first two decades. Tuberculosis in 
children involves the bones and joints in 22 per cent, of cases (Miiller). 

Localization. — Watson Cheyne, from his own and other cases, esti- 
mates that the knee is affected in 16.5 per cent, of cases, the hip in 
14.6 per cent., tarsus and ankle in 14.4 per cent., elbow in 6.3 per 
cent., skull and face in 5.5 per cent., sternum, clavicle and ribs in 5.2 
per cent., pelvic bones in 3.5 per cent., femur, fibula and tibia in 3.5 
per cent., spine in 2.3 per cent., shoulder in 1.5 per cent., and scapula, 
ulna and radius in 1 per cent. Jaffe finds involvement of the spine in 



TUBERCULOSIS OF THE BONES AND JOINTS 357 

20 per cent., foot in 21 per cent., hip in 13 per cent., knee in 10 per 
cent., hand in 9 per cent., and elbow in 4 per cent. 

1. Bones. — Miliary tuberculosis affecting the bones produces no 
symptoms. The spongy ends (epiphyses) of the long bones are the 
particular seat of tuberculous osteomyelitis and periostitis, whence 
infection easily reaches the joints; the diaphyses and flat bones are 
seldom involved. Involvement of the short bones of the fingers and 
toes, and less often of the ulna, may cause bulging, — the spina ventosa, 
which is seen oftenest at about five years of age. In the bone-marrow 
there develops a grayish-red granuloma which dissolves the bone 
{caries sicca); the trabecular necrose and are discharged through fistulas 
as sequesters or "bone sand," in a caseous, pus-like fluid. Even large 
foci may heal by granulating osteitis, in the same manner as tubercu- 
lous adenitis may heal. Infection may remain unobserved or semi- 
quiescent until aroused by such infections as pertussis or measles, or 
by trauma. Cold abscesses in the bone are lined by granulation tissue. 
There may be nocturnal pain, varying in intensity and sometimes 
radiating, stiffness, local tenderness, and fever. Bone lesions are not 
incompatible with seemingly perfect nutrition and otherwise robust 
health. 

2. Joints. — Involvement may occur alone or follow contiguous 
osseous disease. Very often there is synovial inflammation and pro- 
liferation; far less frequently there are isolated tubercles in a non- 
inflamed synovial sac. Serous or serofibrinous synovitis (or the rice 
bodies, corpora oryzoidea) may result from toxins in a neighboring 
focus in the bone, without the actual presence of tubercle bacilli in 
the joint, exactly as toxic pleurisy or pericarditis may result from 
contiguous pulmonary or glandular foci. The symptoms, or onset, may 
be acute or insidious. Pain, especially at night, contractures, and fever, 
may be noted. In the later stages of joint disease, granulation tissue 
forms with large caseous deposits, hydrops, empyema articulorum, or 
the tumor albus (so named because of the thickening of the connective 
tissue, and the oedema and glistening appearance of the soft, peri- 
articular structures). The joint is sometimes quite disorganized. 
Seventy-five per cent, recover under such conservative treatment as 
immobilization, iodoform or formalin injections, soap inunctions, 
cod-liver oil, and sea air. 

Within a few years Poncet first, and then Leriche, Patel, Trebeneau, 
Bezancon, and Griffon, have called attention to a tuberculous pseudo- 
rheumatism, in which the incipient arthritis closely resembles genuine 
rheumatism (rheumatisme tuberculeuse ankylosante) . It is thought 
by these French writers that the exuded leukocytes are strictly of the 
lymphocyte type; inoculations have proven positive in a number of 
cases, but toxaemia is the most probable cause (Mohr). It is most fre- 
quent in children. Lejars found one case of primary tuberculosis of 
the muscles. 



358 THE SPECIFIC INFECTIONS 



XI. Tuberculosis of the Skin. 

1. Lupus. — Lupus is the most frequent form. In 66 per cent, of 
the cases it*is located on the nose, lips, and angle of the eye. It is often 
associated with tuberculosis elsewhere ; Besnier found it with pulmon- 
ary tuberculosis in 21 per cent, and Leloir in 38 per cent.; Sachs and 
Bender found other tuberculosis in 62 per cent, and Block in 79 per 
cent. It is typical granulation tissue with true tuberculous tumors, 
which contain few bacilli because of the low temperature of the skin, 
and it often advances on one border while it cicatrizes on another. 
Its various forms, such as lupus maculosus, exulcerans, or hyper- 
trophicans, need not be described in detail. 

2. Scrofuloderma. — Scrofuloderma, the subcutaneous granuloma of 
Neisser, appears as movable, painless, subcutaneous nodes, which later 
become cold abscesses (the so-called scrofulous gumma, gomme 
scrofuleuse of Despres and Besnier); they discharge a milky fluid 
and leave a granulating ulcer, which is more sharply marked than 
that of lupus. 

3. Lichen Scrofulosorum. — Lichen scrofulosorum is often but not 
always tuberculous; the eruption originates from the follicles, is con- 
stituted of thick, oily, epidermal cells which can be scratched off 
without causing bleeding, and is usually distributed in sharply marked 
groups of isolated yellow or yellow-brown nodules as large as a pin- 
head. 

4. Tuberculosis Cutis Verrucosa. — Tuberculosis cutis verrucosa of 
Riehl and Pautauf is observed on the backs of the hands and fingers 
and in the interdigital folds, chiefly in butchers, cooks, and horse- 
men. 

5. Postmortem Tubercles. — Postmortem tubercles were described 
by Verneuil, Verchere, Pick, and Pfeiffer. Laennec referred his case 
of pulmonary phthisis, though probably incorrectly, to a postmortem 
tubercle. Gerber suffered from tuberculosis of the axillary glands 
following a tubercle. They are observed in butchers, veterinary sur- 
geons, and pathologists, especially in those beyond middle life. 

6. Tuberculous Ulcers. — Tuberculous ulcers may develop from cuts 
by broken sputum cups; from bites of tuberculous subjects, ants, or 
flies; from burns, tattooing, skin grafting, or leeches; and from cir- 
cumcision when the wound is sucked by tuberculous rabbis; lupus 
has followed vaccination. 

Scrofula is tuberculosis; however, in descriptions dealing with 
scrofula as a separate clinical picture, affections of the mucous mem- 
branes are often associated with the skin lesions above described, 
with adenopathies (q. v.), and with bone or joint disease. Among 
these may be mentioned chronic ozsena, rhinitis, adenoids, friable 
carious teeth, otitis media, blepharitis, conjunctivitis or keratitis, par- 
ticularly of the phlyctenular type, tracheobronchitis, intestinal catarrh, 
and leukorrhcea. 



TREATMENT OF TUBERCULOSIS 359 



Treatment of Tuberculosis. 

(A). Prophylaxis. — 1. Antibacillary. — Antibacillary prevention con- 
cerns the etiological factors in the dissemination of the bacillus 
and of the elements of contagion. Cleanliness of the skin; disinfection 
of contaminated faeces, urine, or pus; confiscation of diseased meat; 
and regulation of dairies and inspection of cows are important; but 
the destruction of infective sputum is the prime indication. It is well 
to regard all sputum as dangerous, and to teach the public and patients 
this doctrine. Tuberculous, as well as pneumonic, grippal, and other 
sputa must be destroyed. An appeal must be made to the conscience 
or selfishness of tuberculous patients, setting forth the risks of auto- 
reinfection. Patients should carry small spit cups, of which many 
varieties are made, and the sputum should be destroyed by burning or 
boiling before it dries. Spittoons, unsesthetic as they are, should be 
placed conveniently in the halls and wards of hospitals, sanitoria, 
factories, cars, and stations, either on the floor, or, better, somewhat 
elevated on brackets. The patient should sleep alone, and kissing must 
be interdicted. The bedclothes, linen, and eating utensils, should be 
carefully steamed or boiled. Rooms should be cleaned with moist cloths 
and should be swept with the windows and doors open. The danger 
of swallowing sputum must be clearly set forth, and the mouth should 
be washed out with some antiseptic solution before eating, though a 
few bacilli with the food are not very dangerous, as the gastric juice 
probably destroys them. The more minute details are as impossible 
to describe as those of consistent surgical asepsis, though they are 
equally logical and necessary. In Germany the reduction of mortality 
by 33 per cent, is clearly due to an awakened public intelligence. 

2. Governmental. — Governmental prophylaxis, somewhat less promis- 
ing in republican than in autocratic states, is important. It comprises: 
education of the public by publication of the dangers and preventive 
measures in tuberculosis, as in the recent excellent and plain pamphlets 
of the Illinois State Board; the establishment of sanitoria for the poor, 
among whom the mortality is four times, and the morbidity many 
times, greater than in the rich; the building of separate hospitals, or 
at least wards, for the hopelessly diseased; and the regulation of the 
air capacity of dwelling rooms in tenements, factories, or stores. 
Aside from great suffering and sorrow of thousands in every large 
community, there is an enormous economical waste in work and 
wages, an enormous cost in hospital care, and a great loss in live 
stock, — over 62,000 cattle and 56,000 hogs were condemned in 
Prussia alone in one year. The comparative sociological damage is 
apparent, as the ravages of tuberculosis involve the working years of 
life (15 to 60), while 94 per cent, of the deaths from diphtheria occur 
under ten years. 

3. Individual. — Individual prophylaxis includes the increasing of 
physiological resistance, the maintenance of general health, and the 



360 THE SPECIFIC INFECTIONS 

aiding of sound development in children. Weakly children should be 
brought up in the open air, judiciously fed, watched during acute infec- 
tions, kept but few hours in school, sent into the country during vaca- 
tion, taught moderation, and, later, should be informed as to the 
danger of alcoholism, sexual excesses, and infections. 

(B). Hygienic Treatment. — The three great factors are fresh air, 
proper food, and rest. Bodington (1839), in England, treated cases by 
fresh air, but to Brehmer (1850), in Germany, is due the credit of 
soundly establishing the fresh-air treatment and the curability of 
phthisis. A few of his views are untenable, but many of them are the 
basis of the modern methods practised by McCormack, Driver, Det- 
weiler, Trudeau, Knopf, and others. Patients are treated in sanitoria, 
and those at Nordrach, and Saranac, and many others, have given such 
excellent results that institutions of this class have increased; they 
number 54 in Germany, 30 in France, and are growing in number in 
other countries. Results depend on (a) the extent of the disease; (b) 
the condition of organs other than the lungs, as the pleura, intestines, 
larynx, and heart; (c) the social and financial status of the case. 
Detweiler states that 30 per cent, of his cases recovered and 40 per 
cent, improved; Trudeau brought about recovery in 31 per cent, of 
all, and in 66 per cent, of incipient, cases; Turban considers that 88 
per cent, recover; Rumpf followed 97 per cent, of his cases: 70 per 
cent, of incipient cases were able to work — "the best test of a cure"; 
55 per cent, of those in the second stage, and 23 per cent, of those in 
the third, recovered. One of the chief values of sanitorium treatment 
is that the patient learns the lesson of living properly, which too often 
in general practice is not sufficiently impressed upon him. 

1. Fresh Air. — This is the chief hygienic factor in treatment, at 
home, in sanitoria, or in change of climate, (a) Treatment at home, 
for financial reasons, is especially important, as but 5 or 10 per cent, 
of tuberculous people are able to leave home. The patient should be 
carefully clothed and should recline in the sun with the windows of 
his room open, or should lie on a veranda. He should be outdoors 
for one-quarter to one-half the sunny hours, according to the season 
of year. At night the windows should be kept widely open. Rain, 
snow, dampness, and extreme cold, are no contra-indications, nor are 
fever, cough, or haemoptysis; but wind, dust, and sudden variations in 
temperature, are to be avoided. Very thick clothing, which is so fre- 
quently observed among the poor, is unhygienic. Acute caseous and 
advanced types should generally be kept at home. (b) Sanitorium 
treatment offers the advantage of strict discipline, systematic living, 
and the constant presence of a physician who regulates the details of 
every-day life, gives explicit directions, and cheers the patient. Sani- 
toria should be located near, but well outside of, every large centre of 
population, (c) Change of climate was once considered absolutely 
indispensible; now it is said "to be not without influence/' No 
climate is specific. High altitudes offer the advantage of purer air, 
stimulation of breathing, increase of vital lung capacity, increase of 



TREATMENT OF TUBERCULOSIS 361 

the chest dimensions, growth of the muscles of inspiration, increase 
of metabolism, and stimulation of the appetite and blood-making or- 
gans. Colorado, Arizona, and New Mexico (four to seven thousand 
feet elevation), are excellent for cure and for opportunities for entering 
some permanent occupation after recovery; because of the emphy- 
sema which may be induced, a return to the sea level should be avoided. 
St. Moritz, Les Avants, and Davos (5,200 feet elevation) offer a dry, 
clear, cold, still atmosphere, where patients may reside in summer 
and winter; it resembles the climate of Colorado, Montana and north- 
ern Wyoming. There are also the Peruvian Andes and numerous other 
altitudes, for details of which see Solly's Medical Climatology. High 
altitudes are best adapted to suspected cases, to those with limited or 
incipient lesions, to those with slight cavity formation and little emacia- 
tion, or to more advanced but slowly progressing, or torpid, cases. 
Slight fever or slight haemoptysis are not contra-indications to such 
climates. Moderate altitudes (2,000 to 2,500 feet) probably best serve 
the majority of cases, as Asheville (2,250 feet), the Adirondacks (2,000 
feet), Aikin (2,250 feet), Summerville, Thomasville, etc. The climate 
of Minnesota, Nebraska and Dakota (1,000 feet elevation), is cool 
and dry; dryness is usually more desired than lack of variability. 
Moderate elevations do not induce emphysema, whence return to the 
sea level is easier. The sea level is the best location for the tuber- 
culous aged, for quiescent cases with great cicatrization or extensive 
damage, for those with diabetes, albuminuria, nephritis, scrofula, bone 
disease, marked anaemia, repeated haemoptysis, emphysema, or rapid 
softening, for those with incurable forms, for thin, nervous subjects, 
and for those with exophthalmic goitre. Sea voyages are always 
somewhat experimental, and Robin holds that but 8 per cent, of cases 
are benefited by them; those with incipient forms, or those with 
genito-urinary, glandular, or osseous disease, or with open wounds, 
are often helped. Moist warm climates (at the sea level) are especially 
adapted to laryngeal disease, — as the Bermudas, Florida, the Madeira 
or Canary Islands; patients with dyspepsia and diarrhoea do well 
in Corsica, Palermo, and Capri. Warm, dry climates, as southern 
California, Egypt, Algiers, or the Riviera, are good for catarrhal types. 
Climate alone, without proper rest, diet, and reasonable hygiene, 
rarely benefits. 

2. Nutrition. — Practice differs; most physicians recommend 5 or 6 
meals daily, but some get better results by giving but three meals, 
whereby the stomach is allowed some rest. Feeding varies with 
individuals as to the amount and as to the kind of food. A liberal 
mixed diet of meat, fatty meats, and fish, should be given; well- 
cooked leguminous vegetables (which are advantageously given in 
soups), butter, oil on salads, eggs, milk, cream, bread, pastries, and 
cakes, are the chief articles of diet. Anorexia is a common obstacle 
to full feeding. If it is of the nervous type, patients must be compelled 
to eat, but long hours in the fresh air usually stimulate the appetite. 
With habitually light eaters caution is necessary; beef juice, milk and 



362 THE SPECIFIC IXFECTIOXS 

koumyss, should he given; the amount should be gradually increased 
and other foods should be added. Faradization of the epigastrium, 
cold compresses over the stomach, wine, vermouth, the fluid extract 
of condurango tt$> xv-xxx (Immermann), or strychnia gr. ^o in solution, 
half an hour before meals, are valuable appetizers. Raw beef (zomo- 
therapy), which is especially recommended by Richet and Hericourt, 
has lately come into use; fresh lean meat is cut, soaked for two hours 
in one-fifth its weight of water, is then pressed to extract the blood 
and fluid, and administered, 1 to 2 pounds for moderately sick cases 
to twice that amount for severe cases; it must be freshly prepared 
each time, as it soon becomes tainted. Raw eggs are often given 
between meals, beginning with 1 and increasing to 4, three times daily. 
Fever does not contra-indicate full- or overfeeding. Milk should be 
given, up to 1 or H quarts daily; more than this amount promotes 
gastric atony; it is given to advantage with bread, crackers, or toast, in 
order to divide the curds which form; it may be peptonized, disguised 
with cocoa or cognac, or given by the rectum (v. Gastric Ulcer); 
cream and butter are excellent substitutes for cod-liver oil, and butter- 
milk is indicated when the stomach is weak. Fats and carbohydrates 
are necessary to offset nitrogenous waste; the dark form of cod-liver 
oil (v. i.) 3 lipanin (94 parts olive oil and 6 parts oleic. acid), malt, 
honey, cocoa, nutrose, eucasin, and somatose, are valuable foods. In 
all forms of overfeeding (Debove's suralimentation) the tolerance of 
the stomach must be considered, for this is more important than the 
use of drugs (creosote, cough syrups, or cod-liver oil). Debove's 
method consists of gastric lavage followed by the introduction through 
the tube of 3 ounces of powdered meat, a quart of milk, and one or 
more eggs. Alcohol is at the present time administered less often 
and in smaller amounts than formerly, but is frequently indicated 
symptomatically (v.i.); small amounts of red wine or cognac and 
whiskev in egg-nogs are very valuable as a food and tonic. Tobacco 
should be interdicted; in special cases a cigar or two daily may be 
allowed, but the smoke must never be inhaled. 

3. Rest. — Rest is one of the essentials of Detweiler's therapy. 
Exercise destroys tissue, often induces anaemia, and irritates the heart; 
it is distinctly contra-indicated by fever, emaciation, haemoptysis, 
rapid pulse, nausea, and coughing. It has been well said that "too 
many cases of phthisis walk into their graves ." Late in the treatment 
graduated exercise may be taken. Pulmonary gymnastics and pneu- 
matic differentiation, as that by compressed air, are clearly injurious. 
Patients should lie in the bright sunshine and fresh air, and active 
mental occupation should be carefully avoided. Hardening and exer- 
cise should be obtained by quick, dry rubs with a large coarse towel, 
after which rapid partial, and then general, wet rubs may be instituted; 
cold rubs and hydrotherapy are to be shunned when there is any 
tendency to haemoptysis. 

(C). Specifics. — As yet there are no specifics for tuberculosis. Drugs 
are only of symptomatic value. Parenchymatous injections into the 



TREATMENT OF TUBERCULOSIS 363 

lungs, of carbolic acid, creosote, iodine, and iodoform, have been sug- 
gested by the surgical results attained in lesions of the bones and 
joints; but they are not without danger. Koch's original tuberculin, 
his later tuberculin TR, Maragliano's serum, and Behring's efforts 
to immunize cattle, have given no certain results. 

(D). Expectant or Symptomatic Treatment.— 1. Fever.— Rest, 
quiet, digestible food, and fresh air, or change of climate, are 
indicated in great preference to drugs. Brehmer administered strong 
wine at the time the fever began to rise; arsenic is recommended by 
Pollack and Powell, but no remedy in safe or harmless doses con- 
trols fever. Quinine disturbs the digestion. Sponging is fairly 
efficacious. 

2. Cough. — A slight cough serves to remove secretion, but, if exces- 
sive, it begets coughing by congesting the lungs and tubes; the dangers 
of excessive coughing are exhaustion, depression, insomnia, aspiration, 
and vomiting, which necessitate interference. Fresh air, and avoid- 
ance of dirt, dust, and smoke, are most beneficial. Rest in general, 
and especially after eating, should be enforced. The cough should be 
suppressed, for it is certainly somewhat under the control of the will ; 
the comment on the absence of coughing, especially at the table, is 
universal among observers of sanitorium methods; slow breathing, 
with the head slightly thrown back, moist compresses, or the sipping 
of warm water (with 10 grains of salt), often aid in its suppression. 
Creosote was discovered by Richenbach, in 1832, and was used by 
Addison, Sonnenberg, and Jaccoud; it is not specific, but often in- 
creases the appetite, modifies abundant secretion from the bronchi 
(by which the drug is in part eliminated), and relieves the cough. 
Administration in the fluid form is better than in capsules, which are 
often undigested. Beginning with one drop (well diluted) after meals, 
the dose may be increased to ten times that amount; but full dosage 
often irritates the stomach and kidneys and necessitates constant 
supervision of the urine; it should not be given in febrile cases nor in 
haemoptysis. 

Creosote may be administered in milk, in water with the compound 
tincture of gentian (5iij), or in sherry wine. 

Creasoti 5iss. 

Glycerini . . §ss. 

Tr. gentianse co q.s. ad §iv. 

M. et S. — One teaspoonful after meals. 

Creosote may be given in pill form as follows : 

Creasoti diss. 

Mucilag. acaciae oiij. 

Pulv. althseae q.s. 

M. et ft. pil. no. 100. 
S. — One after meals. 

Guaiacol carbonate (gr. v, p. c.) is often better tolerated by the 
stomach than creosote. Cod-liver oil, first used by Hughes-Bennett, 



364 THE SPECIFIC INFECTIONS 

is usually given in doses so large as to disturb gastric and intestinal 
digestion; the first dose should be 10 drops and the amount should be 
gradually increased. It is more valuable in tuberculosis of the glands 
and bones than in the other types. Eructations can be avoided by 
administering it one or two hours after meals, when the food begins 
to leave the stomach. The oil is readily absorbed, because of the bile 
which it contains, and is possibly somewhat alterative; but it is not 
very superior to butter or cream, and is really more a food than a 
medicine. Cod-liver oil may be floated on whiskey or milk, and 
gulped down. Its taste may be partly disguised by a "chaser" of 
whiskey, or by floating it in beer or porter. Syrup of orange disguises 
its taste fairly well. It is seldom given when there is fever or indigestion. 
It is prepared in large capsules, which obviate its unpleasant taste. 
Opiates may be used, such as paregoric; codeine gr. J with aq. lauro- 
cerasi and glycerine aa tt^xv and syr. tolutani 3j q.i.d.; dionin gr. ^ 
q.i.d.; heroin gr. 20 q.i.d.; even morphine sulph. gr. J with ac. 
hydrocyanici dil. n^ii. Other remedies are myrtol gr. ii. a.m. and p.m. ; 
terpin hydrate gr. ii to v, t.i. d.; ol. terebinthinse, ttjuj and for un- 
productive coughs, spts. chloroformi or spts. setheris co. §ss in whiskey, 
p. r. n. (Various formulae are given under Bronchitis.) 

Tr. belladonnas oss. 

Spr. chloroformi oiss. 

Mucilag. acacise 5j. 

Aquae ". q.s. ad §iij. 

M. et S. — One teaspoonful after meals, or as indicated. 

Expectorants are to be avoided because of their nauseating tenden- 
cies. Tr. benzoin co., and creosote, may be vaporized. Menthol and 
guaiacol aa may be taken internally in olive oil. If the cough is naso- 
pharyngeal, the mucosa should be painted with iodine, potas. iodide, 
and glycerine, in proportions of 1, 10, and 100; if laryngeal, 20 per 
cent, menthol should be applied locally (v. Laryngeal Tubercu- 
losis); if due to enlarged bronchial glands, inunctions of green soap 
and potas. iodide internally, should be given. 

3. Sweats. — The room should be cool at night, the windows open, 
the bed not too heavily covered, and the body protected by a flannel 
night-gown. A glass of cold milk, with 5ij of cognac, given at bed- 
time, is often beneficial. Morphine on retiring is indicated when the 
sweats are associated with cough and insufficient oxygenation. Atro- 
pine gr. too to so, and camphoric acid gr. xv to xxx, at bedtime are 
the most reliable remedies, and are superior to aromatic sulphuric acid 
tt£x to xx, agaricin gr. tV to tV, tr. nucis vomica? ir#xxx, picrotoxin 
gr. 6b and muscarin tt#v of a 1 per cent, solution. 

Quininae sulph oss. 

Calcii hypophosphitis oj. 

Extr. nucis vomicae . . . . . gr. v. 

M. et ft. pilulae 20. 
S. — One after meals. 



TREATMENT OF TUBERCULOSIS 365 

4. Haemoptysis. — Exertion, loud talking or singing, and excesses in 
alcohol, venery, coffee, or tobacco, must be shunned in all cases. It 
is well to warn patients of the possibility of haemoptysis, in order to pre- 
vent undue excitement, if it appears. Effusive pleurisy should not be 
tapped in a subject who has recently bled from the lungs, as thoracocen- 
tesis has produced fatal haemoptysis. The chief indication is absolute 
rest, physical and mental; the patient should be kept in the semire- 
cumbent posture; silence on his part should be enforced; massage 
and stimulants are contra-indicated; no physical examination should 
be made except by auscultation, as percussion is obviously dangerous; 
and a hypodermic injection of morphine should be given to lessen 
cough, to quiet the heart, to allay the excitement attending most hemor- 
rhages, and also possibly for its slight haemostatic effect. As the tonus 
of the pulmonary vessels is beyond regulation, ergotin, tannic acid, 
and other haemostatics, are useless, though digitalis and fresh supra- 
renal extract gr. ii to v sometimes seem efficacious. Salt 5 j i s a popular 
remedy and is supposed to act by stimulating the vagus. An ice-bag 
should be placed over the heart and one over the lung, if rales are 
heard. Deep breathing seems to lessen bleeding. Ol. terebinthinae 
TTjrij to iij is considered the best drug by Fraentzel. In severe or ob- 
stinately recurrent hemorrhage, bandaging of the extremities (Hip- 
pocrates), to lessen the return flow of blood, injections of gelatin, 
induction of pneumothorax by gas injection or puncture (Murphy, 
Cayley), or even emetics to stimulate the vagus (Fraenkel) may 
possibly be indicated. Rest and the administration of morphine, 
however, are usually effective. 

5. Pain. — Pain may be pleuritic, and should be treated by adhesive 
straps or by painting with iodine; if muscular, it should be treated 
by codeine to relieve coughing, by liniments, massage, fomentations 
or phenacetin. 

6. Dyspnoea. — This is not common. If due to stagnant secretion, 
moderate movement or change of posture aids in its evacuation; if 
asthmatic, iodide gr. iij after meals is indicated but it must be 
given with care lest it congest the lungs; if dyspnoea results from 
compression of the vagus by bronchial glands, iodide and green- 
soap inunctions should be given ; if cardiac, alcohol or strychnia is indi- 
cated; if caused by pleuritis or pneumothorax, these affections should 
be treated. 

7. Cardiac Weakness. — To relieve cardiac weakness, rest, an ice- 
bag over the precordia, cognac, champagne, camphor, or strychnia, are 
superior to digitalis or strophanthus. 

8. Insomnia.— To relieve insomnia the patient should have sun- 
light, and also fresh air night and day; a light, early evening meal, 
a glass of beer, porter, or some whiskey on retiring, the bromides, 
codeine, morphine, and galvanization of the neck and head, are 
beneficial. 

9. Gastro-intestinal Symptoms. — Nervous anorexia is relieved by 
fresh air, forced feeding, electricity, and guaiacol (v.s.). Dyspeptic 



366 THE SPECIFIC INFECTIONS 

symptoms necessitate a scant diet for a few days, feeding by rec- 
tum, and poulticing of the epigastrium. In gastric atony, frequent 
meals of small volume, limitation of fluids, and strychnia, are indicated. 
For gas formation or pain the following are indicated : carbolic acid 
gr. j; resorcin gr. iij; fluidextract of gelsemium rr^ij; bismuth; extr. 
belladonna or spts. chloroformi ttjjxx. Pyrosis may be corrected by sod. 
bicarb, and magnesia usta aa gr. xv to xxx. Hyperacidity should be 
treated by milk diet, belladonna and Carlsbad water or other alkalies; 
anacidity is relieved by easily digested foods, as somatose or eucasin; 
and subacidity by hydrochloric acid. Vomiting is caused by irritation 
of the pharynx (Lugol's solution locally, or gargles [1 to 10] of pot. 
bromide), the cough, overfeeding, or overmedication; small doses of 
carbolic acid (v. Typhoid) are most successful. Constipation (q.v.) 
is treated by the usual measures. Diarrhoea may be dyspeptic, catar- 
rhal, toxsemic, ulcerative, or amyloid; the following is indicated: 
Tannic acid gr. v; opium gr. j; lead acetate gr. ij; camphor gr. ij; 
tannigen gr. vij to xv, or bismuth 3j ( see Typhoid). 

10. Anaemia. — This is benefited by fresh air, change to a high alti- 
tude, full diet, iron in small doses, and arsenic. 

11. Sexual Symptoms. — Intercourse must be forbidden in incipient 
as well as in advanced cases. Two or three years after recovery 
marriage may be sometimes allowed; it is generally less injurious to 
men than to women. Tuberculous parents may rear healthy children, 
but tuberculosis and scrofula are rather common in such families. 
In 66 per cent, of pregnant tuberculous women the prognosis is bad, 
and laryngeal tuberculosis is almost invariably fatal within a short 
time. In severe cases abortion may be contemplated; opinions vary 
as to its indication, for some contend that the mother runs the greater 
risk and others maintain that abortion has no appreciable effect on 
the tuberculous process; Kaminer found that in 70 per cent, of the 
cases abortion does not alter the clinical course. 

12. Treatment of Other Complications. — The treatment of laryngeal, 
pleural, peritoneal, intestinal, glandular, and meningeal complications 
(v. s.) is considered elsewhere. 



LEPROSY. 

Definition. — A chronic incurable contagious disease, caused by the 
Bacillus leprae and characterized clinically by nodules, which belong 
to the infective granulomata (Lepra tuberosa), and are observed ex- 
ternally on the skin and nasal and oral mucosae, and internally in 
many organs; or by a perineuritis leprosa, which causes sensory, 
motor, and other symptoms (Lepra maculoansesthesia). The nodular 
and anaesthetic forms usually co-exist in some measure, though in 
varying degree. 

Distribution. — The home of leprosy is Egypt, where it existed 2,400 
years B.C. (Brugsch) or even 4,620 B.C. (Engel-Bey). The leprosy 



LEPROSY 367 

of Leviticus probably includes other diseases. It prevailed in India 
700, and in China 400, years B.C. Just before the Christian era, Pom- 
pey's soldiers brought leprosy to Italy, whence it spread over Europe, 
and the Crusaders at the end of the thirteenth century further dissemi- 
nated the disease. In Europe there were 20,000 asylums, but some 
cases were probably syphilis; the disease has steadily decreased since 
the sixteenth century. It is estimated that at present there are 300,000 
cases in the world. In Europe cases are found in Sweden, Norway, 
Finland, Russia, Dalmatia, Bosnia, Montenegro, Germany, France, 
Italy, Spain, Portugal, Turkey, Greece, and in some Mediterranean 
islands; Arning estimates that there are 3,000 cases in the west half 
of Europe. In Asia numerous cases are found in India (5 cases to 
each 10,000 of population), China, Malay Archipelago, Formosa, 
Corea, Persia, Turkestan, Syria, and Arabia. In Africa it prevails 
in Egypt along the Nile, in Tripoli, Tunis, Algiers, Mozambique, 
Zanzibar, Madigascar, and in the Canaries and Azores. In Japan, 
Australia, Oceanica, and Sandwich Islands, it is also found. In 
America foci exist in Canada (New Brunswick, Nova Scotia, and 
British Columbia), in the United States (California, Louisiana, Minne- 
sota, North Dakota, Florida); in Mexico, West Indies, Honduras, 
Columbia (5 per cent, of the population), Brazil and Paraguay. 

Bacteriology. — The Bacillus leprae was found by Hansen (1871) 
and was fully described by Neisser (1879). It is a fine, narrow rod, 
measuring J to f of a red cell, and closely resembles the tubercle 
bacillus (q. v.) morphologically and in its staining .properties; both 
bacilli contain fat. Inoculation is the surest differential criterion 
between the two, for the lepra bacillus is not inoculable. When in 
the internal viscera it may exceed the dimensions which it attains 
in the skin and mucosae five or six times (Cornil). It is motile and 
cannot be cultivated. It is found in the typical nodes and infiltrations 
of the skin and superior mucosa?, in the fresh maculae and in recent 
nerve disease, in the sweat, in the sebaceous and hair-glands, and it 
is free in their lumen. It also exists in the nerves and Pacinian bodies 
of the skin; in the brain, cord, eye, lungs, liver, spleen, intestine, and 
kidney; in the salivary, pancreatic, adrenal, and lymphatic glands; 
in the larynx, testis, epididymis, tubes, ovaries, and bloodvessels; 
in the blood during fever (metastatic distribution), and in the nasal, 
dermal, faecal, lachrymal, bronchial, vaginal, urethral, and mammary 
secretions and excretions. It is not known why the bacillus is found 
so much more frequently and persistently in the nodular and mixed 
types than in the nervous forms; Strieker found it in the nasal secre- 
tion in 96 per cent, of the nodular, 96 per cent, of the mixed, and in 
66 per cent, of the nervous, type. It has never been identified outside 
of the human body or of its secretions and excretions. It corresponds 
to but one of Koch's criteria; i.e., it is always present in leprosy; it 
cannot, however, be cultivated, and the value of successful inocula- 
tions on criminals under sentence of death has been justly criticized, 
for these cases developed in a leprous community. That leprosy is 



368 THE SPECIFIC IXFECTIONS 

contagious can no longer be doubted, as shown by its increase where 
no restriction is enforced, by its decrease on segregation, by its develop- 
ment in two-thirds of the (colored) attendants in lazarettos, and by 
other factors. It is less communicable than syphilis or tuberculosis 
and is promoted only by long and intimate contact with lepers. The 
nodular is far more dangerous than the anaesthetic type. Infection 
may be direct or indirect (by infected linen, utensils, etc.). It occurs 
chiefly though the skin and nose, and possibly also through the gen- 
italia. Vaccination has probably never caused it. Extension occurs more 
by the lymphatics than by the bloodvessels. Hereditary transmission 
is improbable; a predisposition toward leprosy may possibly be in- 
herited, but not the disease, and only 4 per cent, of children of leprous 
parents acquire it. More cases occur in colored than in white races, 
more in men than in women, and more in the poorer than in the upper 
and middle classes. It most frequently occurs between the ages of 
fifteen and thirty, and rarely before the third year. 

The incubation is long, at least three to five, and sometimes ten, 
twenty, or even thirty-two, years. 

Symptoms. — The chief clinical groups do not include the visceral 
involvement which is seen in every type; the main types are nearly 
always somewhat blended. 

I. Nodular Type (Lepra tuber osa seu tuberculosa). — The prodromal 
toxemic symptoms indicate an infection which has already been estab- 
lished, but has escaped recognition ; they are depression, coldness, 
formication, sweats, pains, vertigo, digestive disturbance, temperature, 
and sometimes nasal irritation. After months, or years, macula? appear 
on the face and extremities, which may itch or may be hyper aesthetic ; 
they may disappear, leave pigmentation, or metamorphose into nodules, 
which are present in 75 per cent, of all cases. The nodule, or leproma, 
is a granuloma and is very similar to the tubercle or gumma; the 
nodes are highly vascular and are formed of a scanty fibrillar reticu- 
lum, in which lie emigrated leukocytes, small round epithelioid cells, 
and the larger multinucleated lepra cells of Virchow, which contain 
close clumps of bacilli. The nodes by fusion form infiltrations which 
are gelatinous, glistening, and yellow-red. The nodes vary in size 
from that of a millet seed, to that of a hazelnut or walnut; they lie 
in the skin, are dark red, and later become yellow-brown; they are 
glistening, vascular, slightly desquamating, and at first soft but later 
become harder. Sensation is always disturbed in their vicinity. They 
are most conspicuous on the face and hands, but also appear on the 
extensor surface of the knee, elbow, and fingers, and very seldom on 
the soles of the feet, the palms of the hands, the scalp, or penis. When 
they develop on the face, the forehead, nose, cheeks, chin, lips, and ears, 
are thickened, the nose becomes flatter, the eyebrows, lashes and 
the beard are shed. The eyes are involved in over 90 per cent, of the 
cases; the expression is leonine (leo?itiasis), or, as the ancients called 
it, faun-like (satyriasis). The nodes usually grow and extend slowly, 
and the lymphatic vessels and glands, of the neck and groin especially, 



LEPROSY 369 

become enlarged and tender. Sometimes the progression is inter- 
ruptedly acute, with intermittent fever and an eruption resembling 
erysipelas. They may shrink, but more often necrose, soften, and 
ulcerate. At the same time or later, nodules which are prone to early 
ulceration and infiltration, occlude the nose, roughen the voice (raucedo 
leprosa), distort the larynx and throat, impair mastication, swallow- 
ing, or respiration, and even provoke suffocation. Cicatrization of the 
throat or face causes added deformity. 

II. Nervous Type (Lepra nervorum, ancesthetica, maculo-ancesthetica, 
sen mutilans). — The most common prodromes are fever and such 
nervous symptoms as rheumatic pains, neuralgia, paresthesia, hyper- 
esthesia, and vasomotor cerebral congestion. Macula? develop on 
the face, neck, trunk, or limbs; they are pale or dark-red, flat or slightly 
raised, growing peripherally and paling centrally, and are glistening 
or present a powdered aspect. Histologically they are identical with 
the nodules, but contain fewer bacilli, are flatter, contain no large 
cells, and tend more toward fibrous change. Their distribution is 
asymmetrical, like that of the underlying nerve lesions; they are often 
oversensitive, sometimes pigmented (lepra nigra), or leukoderma-like 
(lepra alba). Early vesicles sometimes develop. If the skin is pow- 
dered with dry methyl violet and if pilocarpine is then given, the 
sound tissue sweats and stains, while the macule remain uncolored 
because they do not sweat. 

Sensory disturbances are due to lesions in the nerve trunks, which 
are the seat of a perineuritis and interstitial neuritis which slowly 
compress the nerve fibers. The connective tissue development and 
the presence of the bacilli differentiates this from the parenchymatous 
neuritides. Unlike the ordinary neuritis, the leprous neuritis affects 
the sensory more than the motor filaments. There is an irregular 
dissociated anesthesia in which the perception of pain and tem- 
perature is usually more dulled than other forms of sensation, and 
this occurs mostly in the peripheral branches in the arms and legs. 
Sensation may be perverted or retarded, and anesthesia may come on 
suddenly, which is considered rather characteristic. Pain may be 
slight, or agonizing as in a case of ten years duration which was 
personally observed. The nerve trunks are palpable and are tender 
in many cases; the ulnar nerve is most markedly enlarged and in the 
case cited was thicker than a lead pencil, but the auricular nerve is 
more often felt (in 90 per cent., Baelz). Motor weakness and atrophy 
are less common and are rarely extreme; the eyelids, muscles of the 
mouth, and sometimes the masticatory and ocular muscles, and also 
the hands and feet, are paretic. The ulnar and peroneal nerves are 
sometimes paralyzed, causing the "claw-hand" and "claw-foot." 
Facial paralysis occurs in 9 per cent, of cases. The tendon reflexes 
are often increased, though sometimes normal or decreased; there is 
often fibrillation and increased myotatic irritability. Trophic changes 
are less common and include oedema, glossy skin, "mal perforant" 
(26 per cent.), loss of the hair or nails, dry gangrene, bone resorption, 

24 



370 THE SPECIFIC INFECTIONS 

rheumatoid swellings, ankylosis, and pigmentation. Great trophic 
changes mark the lepra mutilans. 

III. Mixed Type. — This is a combination of the nodose and anaes- 
thetic types. In all developed forms the internal tissues are invaded: 
the liver, spleen, and lymph glands, are enlarged; the lungs show peri- 
bronchial foci, cavities, or induration; and the intestine is infiltrated. 
In both sexes the sexual functions are decreased and later are entirely 
lost. Infantilism results in cases developing before puberty. Cachexia 
develops, the patient becomes very sensitive to cold, the temperature, 
except for intermittent rises, becomes depressed, heart weakness de- 
velops, and a degree of apathy is noted. Abortive or long localized 
forms are described. 

Course and Prognosis. — The course is slow and progressive, the 
outcome invariably fatal. The nodular type covers eight to twelve 
years, the anaesthetic form fifteen to twenty years, but either variety 
may endure six or seven decades. According to Hillis, 38 per cent, 
of cases die of leprosy (exhaustion, diarrhoea, cardiac weakness), 
22 per cent, of chronic nephritis, 17 per cent, of lung disease, which 
is more often leprous than tuberculous, and 10 per cent, of diarrhoea 
(leprous infiltration of the gut). The remaining 13 per cent, die of 
erysipelas, sepsis, amyloidosis, and intercurrent diseases, for lepers 
possess a decidedly reduced resistance. 

Diagnosis. — The diagnosis is based on the history of residence and 
of exposure (which is often suppressed by the patient), on the macules 
or leukoderma (which are found in 90 per cent.), on the anaesthesia, 
amyotrophy, and mutilation, and on the finding of the lepra bacil- 
lus (necessary for exactness), for which the nasal secretion, nodes, and 
macules, should be examined (v. Syringomyelia). 

Treatment. — I. Prophylaxis. — All suspicious cases should be regis- 
tered and all clear cases should be sequestrated. 

II. Therapy. — Drugs are useless, though a few are helpful, (a) 
Gurjun oil 3 SS to 5ij m water or lime water; (b) chaulmoogra oil, in 
milk, beginning with a few minims and increasing to 5j _n j 5 ( c ) salves 
of 5 to 10 per cent, pyrogallol, 10 per cent, chrysarobin, 10 per cent, 
ichthyol; (d) Calamette's antivenin, 20 to 30 c.c, which was suggested 
by cases which improved after snake bite; (e) arsenic, salicylic acid 
and corrosive sublimate; these are the most extensively used remedies. 
Symptomatic treatment of pain, ulcers, etc., is also indicated. 



FEBRICULA 371 

INFECTIONS OF UNCERTAIN ORIGIN. 

(A). FEBRICULA. 

Definition. — A fever of short duration, due to a number of causes. 
If only of twenty-four hours duration it is called ephemeral fever; 
when it lasts a few days, it is called febricula; when attended by herpes, 
febris herpetica; or when accompanied by gastric disorder, febris gas- 
trica. 

Febricula is no morbid entity, and its varied causes are not exactly 
known. It embraces (a) benign or abortive forms of various acute 
infections, such as rheumatism, typhoid, scarlatina, tonsillitis, and 
pneumonia; and (6) febrile dyspepsias, especially those in children. 
Gastric fever is a term which was formerly applied to febrile gastritis, 
which is possibly produced by toxins in the food. Sewer-gas is pop- 
ularly held as the cause of fugitive fever with gastro-intestinal disturb- 
ance, but Abbott and others have justly contested its etiological 
significance. Exposure to cold is also a possible factor. 

Symptoms. — The three common symptoms are (a) chill or chilli- 
ness; (6) sudden rise of temperature; (c) a critical resolution, more 
often prolonged than acute. The onset is abrupt, usually without pro- 
dromes. The fever rises quickly to 101°-103°, or higher in the young, 
with the usual signs of toxaemia (headache, coated tongue, anorexia, 
and febrile urine). Herpes is quite frequent. Bronchitis, acute splenic 
tumor, albuminuria, and, in children, cerebral toxsemia, are sometimes 
present. The term ephemeral is rather inappropriate, as the average 
duration is three days, with a slow crisis. 

Diagnosis and Treatment. — The diagnosis is solely by exclusion, 
and the treatment is expectant. Rest in bed is advisable as a precau- 
tion against some longer and insidious malady, such as typhoid ; the 
bowels should be unloaded, the diet restricted, and a drop or two of 
tincture of aconite and spts. setheris nitrosi 5 ss should be given every 
three or four hours. 

(B). GLANDULAR FEVER. 

Definition. — An acute infection observed in children and character- 
ized by pharyngeal injection, a short high fever, and a painful intu- 
mescence of the cervical lymph glands. It was described as Driisen 
fieber by Pfeiffer, in 1889. Its etiology is unknown but it is evidently 
an infection, as suggested by the clinical signs and by its frequent 
occurrence in epidemics. It is usually seen in children between five 
and eight years of age, and during the colder months. West observed 
an epidemic of nearly 100 cases in Bellaire, Ohio. 

Symptoms. — The symptoms begin without prodromes, with fever 
of 100° to 103°, pain in the head and neck, redness of the throat, some 



372 INFECTIONS OF UNCERTAIN ORIGIN 

dysphagia, often pain in the limbs, nausea, vomiting, and abdominal 
pain. On the second or third day the cervical lymph glands become 
swollen and tender, but seldom cause redness of the skin. The glands 
back of the sternomastoid are most involved. The inguinal and axil- 
lary glands are involved in 75 per cent, of cases, and the mesenteric 
in about 40 per cent. The glands may reach the size of an egg. After 
ten to twenty days the swelling subsides, having lasted longer than the 
fever. In some instances a persistent dry cough suggests involvement 
of the bronchial glands. The spleen is enlarged in 60 per cent, of 
cases, and the liver in 90 per cent. The fever lasts but a few days. 
Complications are rare. Suppuration in the glands is exceptional. 
Acute nephritis and otitis media are occasionally observed. 

Prognosis and Treatment. — The prognosis is good, though a relapse 
may occur. The absence of a rash excludes the adenopathies of 
varicella, scarlatina, and measles, and the generalized glandular swell- 
ing excludes the local swelling due to simple pharyngitis. The treat- 
ment is expectant. 

(C). MILIARY FEVER. 

Definition. — An acute infection, probably microbic, marked by fever, 
profuse sweating, a miliary eruption, nervous symptoms, palpitation, 
and precordial anxiety. It first appeared in England after the Battle 
of Bosworth (1486) and broke out several times in the following cen- 
tury. It was known as the " English sweats" (sudor Anglicus), and its 
mortality reached even 50 to 80 per cent. In 1529 it caused 3,000 
deaths in Dantzig. There have been about 200 epidemics between the 
epidemic in Picardy, in 1718, and that in Poitou, in 1887. It is 
apparently highly contagious (Brouardel). Epidemics have also 
occurred in Italy, Switzerland, Germany, and Austria, with a death- 
rate of 5 to 25 per cent. Fortunately they last only a week or-month. 

Symptoms and Treatment. — In mild outbreaks the chief symptoms 
are fever, profuse periodic sweating, and miliary eruptions. The 
eruption may be erythematous or morbilliform (miliaria rubra), or 
there may be no redness of the skin (miliaria alba s. crystallina) ; 
the spleen may be enlarged. In severe cases there are marked cerebral 
toxaemia, rapid pulse, precordial distress, palpitation, extreme pros- 
tration, and hemorrhages into the skin; and death results in a few 
hours or days. Its average duration is one to two weeks. Desquama- 
tion is frequent and convalescence rather tardy. The treatment is 
supportive and expectant. 



(D). WEIL'S DISEASE.— (ACUTE FEBRILE JAUNDICE.) 

Definition. — An acute infection, characterized by fever, jaundice, 
herpes, enlarged spleen and liver, sore throat, muscle pains, and 
albuminuria. It was especially described by Weil (1886), whose name 



MILIARY FEVER 373 

it most often bears, though it was previously mentioned by Mathieu, 
Bouchard, Lancereaux, and Coynes. Nicolaysen describes 63 epidemics 
of icterus in Norway and Sweden in the last fourteen years; 3 to 28 per 
cent, of the inhabitants in certain communities acquired the disease. 

Etiology. — Its etiology is unknown, whence our difficulty in stating 
whether it is a morbid entity or whether it includes several diseases. 
It occurs largely in men between twenty-five and forty, especially in 
butchers and alcoholics; it also occurs in the warmer seasons and 
sometimes in epidemics. The symptoms mentioned above, those 
described below, and the autopsy findings of granulo-fatty changes and 
ecchymoses, mark it as an infection. It is either directly microbic or 
toxsemic. Bordoni, Uffreduzzi and later Jaeger found the Proteus 
fluorescens, and Freund a diplococcus, but the intravitam findings 
are usually negative. It is not typhoid, recurrent fever, sepsis, malaria, 
or phosphorus poisoning, with which it has been sometimes identified. 
Some cases have occurred in this country (Lanphear, Musser, Gui- 
teras); the author has seen eight cases in Chicago. 

Symptoms. — The symptoms begin suddenly without prodromata, 
with fever, chill or chilliness, headache, vertigo, insomnia, and severe 
pains in the limbs and extremities. The fever may reach 104°, 105° or 
107°; it afterward shows remissions, and falls either by crisis or by 
lysis after five to eight days. The nervous symptoms may include 
delirium, sopor, or even coma. Jaundice develops on about the third 
day, is probably due to catarrhal radicular angiocholitis, and may be 
slight or extreme; bile usually appears in the urine, and the stools are 
often acholic, though the author has twice seen deep jaundice with- 
out obstruction of the bile-duct. Muscular pains are very common and 
intense, especially in the calves, which are usually also tender. Artic- 
ular pains are not uncommon. Herpes is very common. The rapid 
pulse is very marked compared with the usual slow pulse of simple 
catarrhal icterus. In one case the author observed blood-stained 
bronchitic sputum. Digestive symptoms are common, such as furred 
tongue, nausea, vomiting, epigastric pain, abdominal distention, and 
diarrhoea, with acholic or bile-stained stools. The liver is enlarged 
and tender in more than 50 per cent, of the cases, the spleen in over 
66 per cent., and the lymph-nodes are frequently affected. The urine 
is albuminous in over 50 per cent.; acute nephritis is frequent; 
hsematuria occurs occasionally, and uraemia exceptionally; the urea 
and the amount of urine are decreased during, and increased after, the 
seizure (ChaufTard's nitrogenous and polyuric crises); glycosuria de- 
veloped in one fatal case. 

Diagnosis. — Weil's disease must be differentiated from recurrent 
fever by its spirillum, and from sepsis and typhoid, — in regard to the 
latter of which it may be noted that icterus may produce a weak 
Widal reaction. Differentiation is more difficult from suppurative 
angiocholitis (q. v.) and acute yellow atrophy (q. v.). 

Prognosis. — This is usually good and convalescence is generally 
established in two weeks; in one epidemic, 11 per cent, of the cases 



374 INFECTIONS OF UNCERTAIN ORIGIN 

died. Recurrence may be anticipated if the splenic tumor has not 
subsided (Mathieu); renal or hepatic insufficiency, pregnancy, haemo- 
lysis with epistaxis and hsematemesis, render the prognosis less favor- 
able. 

Treatment. — The treatment is directed to (a) the intoxication, for 
which calomel and salines are indicated; cold water enemata (Krull 
and Chauffard) increase the renal flow, and, with it, the excretion of 
toxins; (b) the jaundice, for which salines should be given to lessen 
duodenal catarrh; (c) the albuminuria, for which a milk diet is indi- 
cated; (d) muscular pains, for which heat, and massage with chloro- 
form liniment, are most beneficial. 



(E). MILK SICKNESS. 

Definition. — A disease acquired by man from the milk or meat of 
cattle suffering from the "trembles." Cows with the disease, after 
being driven too rapidly, suffer from anorexia, injection of the eyes, 
vertigo, trembling, and convulsions ending in death. Young horses 
and sheep may also acquire the disease. Milk sickness occurs chiefly 
in newly settled countries, as in the Southwestern states, and it is 
still seen in North Carolina. Its origin and pathology are unknown. 

Symptoms. — In man the nervous symptoms are frequently con- 
spicuous, as restlessness, convulsions, or coma, which appear after a 
few days of malaise. The tongue is swollen and heavily coated, the 
breath foetid, the stomach painful and irritable, the fever high and 
sometimes typhoidal. The issue is either fatal, in acute forms, within 
a few days, or recovery may result after weeks. Flesh, butter, cheese 
and milk, from infected animals may, even when boiled, cause death 
when given to dogs. 

(F). MOUNTAIN FEVER. 

(a) Some European cases are due to the anchylostoma and are 
associated with anaemia, (b) Many cases are identical with typhoid 
(Woodruff, Smart, Hoff, and Raymond), (c) Wilson and Chowning 
(1902) think that the disease is caused by a red-corpuscle protozoon 
like that of Texas fever and malaria, though not pigmented; Stiles 
and Craig could not confirm their findings. Cases develop in the 
early spring, and are marked by chill, fever of one to two weeks, rapid 
pulse, epistaxis, albuminuria, rapid breathing, bronchitis, splenic 
tumor, rapid anaemia, moderate leukocytosis, slight icterus, muscular 
pains, and widely diffused macular rash, — which develops on the third 
day, disappears on pressure at first, but afterwards persists on pressure. 
The liver and spleen are enlarged. Quinine may be beneficial in 
some cases. The death rate may be 70 per cent, (d) In high altitudes 
slight fever, associated with headache, dyspnoea, thirst, and malaise, 
is known as mountain sickness. 



FOOT AND MOUTH DISEASE 375 



(G). FOOT AND MOUTH DISEASE. 

Definition. — Epidemic stomatitis, Aphthous fever, or Aphthse epizo- 
oticse is one of the zoonoses and its nature is unknown. Loeffler and 
Frosch have shown that the virus is ultramicroscopic, as it passes in 
full virulence through porcelain filters. The disease, first described 
by von Valentini, in 1695, and known, since the middle of the fifteenth 
century, chiefly affects cattle, sheep, and pigs, but sometimes also 
goats, horses, dogs, and even fowls. In cattle there is fever, swelling 
of the mouth, salivation, and the formation of small, clear vesicles 
on the tongue, gums, lips, and udders. These vesicles soon become 
opaque, and bursting, form small ulcers; emaciation is rapid, and 
the milk becomes yellowish and mucoid. Recovery is usual in one to 
two weeks. The disease spreads very rapidly. It is observed in 
Hungary, Germany, France, Switzerland, England, and occasionally 
in this country. 

Etiology and Symptoms. — In man infection occurs from diseased 
milk (as proven on himself by Hertwig), butter, and cheese, but not 
by the meat of the diseased animal. Open wounds may be directly 
infected. Cattle have been inoculated from man. The incubation 
is three to five days. There are fever, salivation, aphthous ulcers, 
angina, nausea, vomiting, and vesicles on the skin — which have caused 
confusion with vaccinia. Hemorrhages occur in severe epidemics. 
Ebstein has suggested that Foot and Mouth Disease may be kindred 
with the ordinary aphthous stomatitis of nurslings, or pregnant women. 
Children are more endangered than adults. The death-rate is 2.3 
per cent. (Hulin) to 8 per cent. (Siegel). Recovery usually occurs in 
two to three weeks. 

Treatment. — Prophylaxis concerns the boiling of suspected milk, 
the segregation of diseased animals or human subjects, and vaccina- 
tion, as discovered by Loeffler. A dram of 5 per cent, solution of potas. 
chlorate, t. i. d., should be given, and the aphthae should be touched 
with borax or silver. 



SECTION II 



DISEASES OF THE CIRCULATION. 



DISEASES OF THE PERICAKMUM. 

(A). PERICARDITIS. 

Definition. — An inflammation of the pericardium, usually secondary 
to infectious diseases, to inflammation in contiguous tissues, to other 
diseases of the pericardium, or to dyscrasise; it is fibrinous or plastic, 
exudative, or adhesive. ^_i 

Etiology. — The disease is rarely primary, and final analysis usually 
demonstrates that the so-called primary cases are tuberculous, rheu- 
matic, or septic. Cold, exposure, and trauma, probably only reduce 
the physiological resistance of the tissues to bacterial invasion. Peri- 
carditis is usually mycotic, the organisms of suppuration, pneumonia 
and tuberculosis, being most frequently found; it seems, however, that 
toxins alone may excite inflammation. 

Pericarditis is almost invariably secondary (a) to infectious diseases, 
of which rheumatism (14, 37, 66, per cent.) is foremost, and it is most 
frequent when many joints are involved in rapid succession. Peri- 
carditis may be the only manifestation of rheumatism. Many 
"primary "cases are probably rheumatic. It occurs with recurrent rheu- 
matism, with endocarditis, and sometimes with chorea. It usually 
develops rather early, within half a week to two weeks, but may pre- 
cede arthritis, especially in children. It is commonly serofibrinous, 
most exceptionally purulent. 

It is common in pneumonia, septicopyemia, puerperal fever, ulcera- 
tive endocarditis, navel infection in babes, osteomyelitis, scarlatina, 
and more rarely in other exanthemata, and in tuberculosis (pulmonary, 

377 



378 DISEASES OF THE CIRCULATION 

multiple serous inflammations, pleuritis, peritonitis). In children, 
scarlatina and rheumatism are most important. 

(b) It is secondary, by contiguity, to adjacent affected organs; to 
pleurisy, pneumonia, and aneurysm; to disease of the ribs, sternum, 
bronchial glands, spine, oesophagus, stomach (ulcer and cancer), spleen, 
liver (abscess), peritoneum, myocardium, and endocardium; and to 
cervical cellulitis (diphtheria, mediastinitis). Trauma of these parts, 
from without or within, such as penetration of foreign bodies, may be 
included under this class. 

(c) It is secondary to certain diseases of the pericardium, as tubercu- 
losis, carcinoma, and other processes. In 30 per cent, of Matter's 
"cryptogenetic " cases, tuberculosis was found at autopsy. 

(d) It is secondary to cachexia? or dyscrasiw, gout, diabetes, car- 
cinoma, to nephritis (3 to 10 per cent, of cases, especially those of con- 
tracted kidney), to alcoholism, blood diseases, and scurvy; and often, 
as a terminal infection, to reduced physiological resistance, in which 
case it may easily escape recognition clinically. This class is usually 
found in adults. Though encountered at any age from f cetal life to 
old age, it is most frequent between the fifteenth and thirtieth years. 



Fibrinous (Plastic) Pericarditis. 

A strict division into dry (plastic) and exudative (effusive) pericar- 
ditis is impossible, because the forms are very often combined. Dry 
(plastic, fibrinous) pericarditis is circumscribed over the base and large 
vessels, or is diffuse, and consists pathologically of vascular injection, 
punctate ecchymoses, loss of the smooth, glistening, mirror-like ap- 
pearance of the serous membrane, and exudation of plastic lymph in 
small particles or irregular lamellae, which may appear smeared as 
with butter, spongy, shaggy, or hairy (cor villosum). Some fluid is 
usually found in the meshes of fibrin. Stripping off of the fibrin may 
reveal tubercles. The subjacent myocardium often suffers infiltration 
and degeneration in the more intense or protracted cases. 

Symptoms. — Symptoms are lacking in most cases; pain is incon- 
stant, and, when present, is by no means characteristic. 

Physical Findings. — Inspection and percussion are usually negative. 
The writer has seen a strong apex beat where the autopsy revealed a 
fibrin deposit which was an inch in thickness. Palpation may disclose 
a friction fremitus, usually over the sternum, which may be obtained 
as frequently as is friction on auscultation {described under Pericarditis 
with Effusion, to which refer also for diagnosis, prognosis, and treatment). 



Pericarditis with Effusion. 

This form has been called the second stage, the fibrinous or dry form 
being the first stage. The fluid may be serous with much or little cellu- 



PERICARDITIS WITH EFFUSION 379 

lar or fibrinous admixture (sero-fibrinous) ; it may be hemorrhagic, 
this type being observed in the aged, in the dyscrasise (such as those 
having scurvy or cancer), in cases of tuberculosis, in those having pur- 
pura, hemorrhagic exanthemata, or Bright 's disease; the exudation 
may be tinged with fresh or with darker altered blood ; it may be puru- 
lent, and is then usually sero-fibrinous rather than purely purulent, 
and is often associated with pyaemia or contiguous suppuration; it 
may be putrid, when caused by pyaemia, carcinoma of the oesophagus 
or stomach, or by lung cavities. (Sixty-seven per cent, of pericarditis 
cases are sero-fibrinous, 19 per cent, are hemorrhagic, and 14 per cent, 
are purulent [Breitung].) The pathological sequences of pericarditis are 
fatty and cloudy degeneration, inflammatory infiltration, or actual exul- 
ceration of the heart muscle; rupture of a purulent exudation exter- 
nally into the tissues of the chest, or possibly into neighboring organs or 
cavities; inflammatory extension outside of the pericardium (pericar- 
ditis externa) and thence to other tissues, such as the mediastinum or 
pleura; formation of polypi, which, becoming detached, may, in rare 
cases, produce foreign bodies in the pericardium; complete resorption 
of the exudate and restitutio ad integrum, which is a rather uncommon 
issue; the formation of hard plaques, maculce tendineaz, which are 
usually not inflammatory in origin; organization of connective tissue, 
either as local adhesions, which are mostly observed near the fixed 
base of the heart, because the heart's movements probably detach 
apical adhesions, or as general obliteration of the sac (concretio peri- 
cardii) ; and, finally, desiccation of the exudate, leaving a cheesy mass 
which may become tuberculous or may calcify. Coincident endocar- 
ditis is less a sequence than an associate or cause of pericarditis. 

Symptoms. — All symptoms are frequently absent (Latham, Graves, 
Stokes), and no symptom is diagnostic. Leudet found total latency 
of symptoms in 55 per cent, of his cases. Daily examination of the 
heart in those diseases which are most likely to cause pericarditis is 
the only certain method of avoiding diagnostic errors. Fever may 
exist from the disease, or from the causal affection, but is irregular 
(Wunderlich). It is often absent, especially in secondary pericarditis, 
and the temperature may be subnormal, even in purulent effusions. 
High fever is infrequent even in rheumatic cases. 

Dyspnwa, or thoracic oppression occur. Oppolzer observed cyano- 
sis without dyspnoea when the pulmonary circuit remained intact. 
Dyspnoea is due largely to heart compression by the exudate or exten- 
sion of inflammation to the myocardium, and is less frequently due 
to vagus irritation, phrenic-nerve inflammation, venous, pulmonary, 
and arterial compression. It is remarkable that patients may some- 
times walk into the hospital with enormous pericardial effusions. The 
respirations are increased. 

Pain is variable, is often absent (in secondary pericarditis"), and is 
said to be more common in small effusions. Severe pain oftener indi- 
cates pleurisy than pericarditis (Bouillaud). Epigastric pain may 
precede pain elsewhere (Gueneau de Mussy). Anginal pain (Andral), 



380 DISEASES OF THE CIRCULATION 

radiating to the shoulder, arm, and neck, is rare. Precordial tender- 
ness is at times present, and palpitation is common. 

Cerebral Symptoms. — Delirium, anxiety, restlessness, insomnia, 
mania, choreiform movements, convulsions, psychoses (Burrows and 
Flint), or even coma, may be due to pericarditis, or to complicating 
ursemia or endocarditis. The symptoms may be suggestive of gas- 
tritis, while pericarditis is found on examination. Vomiting, singul- 
tus, dysphagia, recurrent nerve paralysis, and tracheal cough, are 
symptoms of pericardial pressure. 

Physical Findings. — The definite diagnosis depends on the physical 
findings. These are obtained as follows : 

1. Inspection. — Precordial prominence, voussure, first noted by 
Louis, may occur when the chest is plastic, as in women and children, 
and when the intercostal muscles are paretic from inflammatory 
oedema. The left chest often moves less than the right, since the left 
lung is usually compressed. An epigastric tumor-like bulging of the 
luxated liver was noted by Auenbrugger and Corvisart. The apex- 
beat is somewhat lower when exudation depresses the diaphragm; it 
is more horizontal, more to the left, and the dulness transcends the apex 
to the left. The greater the effusion, the weaker the apex becomes, and 
disappearance of the previously distinct apexbeat is all-important. There 
may be only an indefinite, diffuse cardiac impulse. On bending for- 
ward the apex beat or cardiac impulse usually reappears. The inter- 
spaces may bulge. Collateral oedema of the chest wall (Rendue) is 
most rare. Undulation, described by Senac, is not due to the exudate, 
but to the heart itself. Graves and Stokes described tumor-like extru- 
sion of the compressed lung above the clavicle. According to Ewart, 
the upper edge of the first rib can be felt as far as its sternal attach- 
ment, being separated from the clavicle ("first rib sign"). The veins 
of the thoracic wall are large. During convalescence the apex may 
retract during the systole. The decubitus is usually dorsal, or left- 
sided, rarely right-sided, for this compresses the sound lung; the head 
and shoulders are usually elevated, and the attitude is fixed and rarely 
changed. The knee-hand position was noted in Zehetmayer's case. 

2. Palpation. — Palpation confirms the location of the apex. The 
friction rub is often felt. In Fuller's cases of palpable rub, there was 
always external pericarditis which favored conduction of the pericar- 
dial friction. Disappearance of an apex beat previously observed, and 
the presence of a strong radial pulse, is very important, because mere 
absence of the apex is observed in many conditions. Epigastric tender- 
ness on either side of the ensiform, or tenderness between the attach- 
ments of the sterno-mastoid,is due to inflammation of the phrenic nerve 
(Gueneau de Mussy and Peter). Fluctuation is practically never felt. 

3. Percussion. — Three to five ounces of fluid are usually necessary 
to produce distinct physical signs, though Fraentzel has detected the 
presence of one and one-half ounces. There are two complementary 
recesses in the pericardium : one over the basal vessels, where the fluid 
may accumulate, in which case it is early revealed by a triangular dul- 




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PERICARDITIS WITH EFFUSION 381 

ness, whose apex is directed downward (Skoda, von Dusch, Oppolzer), 
which may compress the large veins or arteries; and the other in the 
fifth right intercostal space (Rotch, Ebstein), where the fluid exudate 
replaces the relative liver dulness, and is most easily recognized by 
palpatory percussion. Extensive exudates produce an outline usually 
designated as triangular, with the blunted apex upward, or as pyri- 
form with the base directed downward. The dulness may even reach 
the interclavicular notch, the right nipple, or the left axilla, and may 
impinge on Traube's semilunar space, extend beyond the left lobe of 
the liver, compress the lungs, and markedly depress the diaphragm 
and liver. The dulness is, at times, trapezoidal (see Plate VIII, Fig. F.) 
rather than triangular. Very massive exudates may be mistaken for 
pericarditis plus pleurisy with effusion. Though the outline is roughly 
triangular, the right border is more vertical than the oblique left border, 
which is beyond the apex beat, if the latter remains visible (Skoda). 
The apex beat is dislocated abnormally when the patient lies on his 
side, because the pericardial sac is larger than normal, and permits 
greater cardiac movement. German writers hold that the heart falls 
back in the fluid, but the French think it comes forward. The dulness 
varies with fluctuations in the effusion and with resorption. When the 
patient is in the erect posture, the dulness may be one-third to one-half 
as broad again as when he is in the dorsal position; it also is not so 
high (Gerhardt). This is not invariable, because the lung borders 
must be normal and the exudate freely movable to allow free shifting 
of the fluid. Sahli also found increase in dulness when the subject was 
in thesittingpostureincaseof an enlarged heart, and in valvular disease; 
this he explains as caused by depression of the diaphragm, or by the 
emptying of the blood from the auricles. He thinks the lateral more 
important than the upper border. Sitting is usually unnecessary and 
often dangerous to the patient. Change of the dulness, especially 
when the patient lies on the right side (Rosenbach), is important, for 
this is uncommon physiologically, whereas the shifting of dulness in 
the left decubitus is of minor value. 

Dulness may persist from cardiac dilatation, or from pulmonary 
retraction. The effusion may be enormous (10 quarts, Kyber; or 
8 pounds, Corvisart), and may lead to a diagnosis of pleurisy, or 
pleurisy plus pericarditis. As the normal pericardial sac holds only 
two-thirds to three-quarters of a quart (650 to 800 c.c), the pericardium 
must be greatly relaxed by the inflammation, to allow such large effu- 
sions. The pericardial dulness may not be typical when the effusion 
is largely covered by emphysematous lungs, or when the borders of the 
lung are adherent and cannot be pushed back by the effusion. 

4. Auscultation. — Auscultation reveals the chief and most reliable 
diagnostic sign, the pericardial friction due to attrition of the inflamed 
pericardial surfaces, (a) It is usually a "to-and-fw" rubbing which 
is not exactly synchronous with either the systole or diastole, which 
character is most clear when the heart is slow. It is less often single, 
and occurs mostly late in the systole; it may be triple, i.e., presystolic, 



382 DISEASES OF THE CIRCULATION 

systolic, and diastolic. It is often absent in fibrinous, hemorrhagic, or 
purulent inflammation. In contradistinction to pleurisy, where the 
effusion of fluid abolishes the primary friction, it may be present, even 
with great exudation (Stokes), especially at the base, since here the 
heart may displace the fluid and touch the parietal pericardium. A 
certain consistence of the fibrin seems necessary to friction, for the 
latter is absent in very soft fibrinous deposits. (b) In quality, it 
may be harsh, soft like a gentle and interrupted scratching of the 
ear with the finger, whistling, creaking, crunching, musical, or 
even metallic (resonance from the stomach or intestines). (c) In 
location, it is most often heard over the base or the tricuspid region, 
where it is especially significant. It may also be heard over the apex. 
Sears describes a case in which the friction was heard most clearly 
at the angle of the left scapula, (d) It is very superficial, and close 
to the ear, not deep as in endocardial murmurs. Superficiality of 
the friction sound is absent when partial adhesions exist anteriorly, 
and the fluid accumulates behind the heart. (e) Its propagation 
is not wide (il nait et meurt sur place, Jaccoud), though it has been 
heard at a distance of nine feet. In children it may be heard over the 
whole chest, and the author has once seen the same in an adult. Coin- 
cident hydrothorax (Graves) has been thought to favor its propagation, 
and cardiac hypertrophy, by bringing the heart closer to the chest 
wall, propagates the friction more widely (Stokes). The murmur 
usually ceases abruptly when the stethoscope has been removed a 
short distance. It does not follow the same lines of propagation as it 
does in valvular heart disease. Propagation along the sternum is not 
uncommon. (/) Inspiration usually increases the murmur (Traube), 
and this is due to the closer apposition of the pericardial leaves, caused 
by the movable wedge of expanding lung. (Sometimes it is more 
marked during expiration [Lewinski, Paul], particularly when adhe- 
sions exist between the heart and lung [Riegel].) (g) Moderate pres- 
sure usually increases the friction, especially in plastic chests, though 
pressure may also accentuate valvular murmurs, and much pressure 
may inhibit the cardiac action (Friederich). Change of posture (Cor- 
rigan, Stokes), e. g., leaning forward, often makes the murmur clearer. 
(h) The murmur is variable, now present, now absent, now systolic, 
or again systolic and diastolic, varying in acoustic properties, or chang- 
ing with change of posture; it is often short lived, lasting sometimes 
but two to six hours. It is frequently stated that, as exudation in- 
creases, the friction disappears, but returns again during absorption. 
"It increases upward during exudation, and downward during absorp- 
tion" (Sibson). Nevertheless, friction often persists when there are 
large exudations, if, indeed, its persistence is not invariable (Walshe). 
Balfour claims that friction, once heard, is never effaced by even the 
greatest effusion. It is not dependent on the intensity of the inflamma- 
tion, but rather upon the accidental quality of the effused lymph and 
its location. Disappearance of the rub is explained by (i) regression; 
(ii) exudation; (hi) adhesions; (iv) weak heart. 



PERICARDITIS WITH EFFUSION 383 

As a rule, the heart tones gradually become more or less weakened 
and distant. 

The arrays outline the pericardial effusion. 

Secondary Physical Signs. — There may be evidences of cardiac 
incompetence, which is due to the mechanical hindrance, by the fluid, 
of the diastole, especially of the auricles; it is also due to myocardial 
inflammation or degeneration, or to coincident cardiac disease. The 
signs of cardiac incompetence are hepatic and renal stasis, ascites, 
oedema, cyanosis, dyspncea, cerebral anaemia (syncope), distention 
and pulsation in the jugular veins, and oedema of the lungs. The pulse 
at first undergoes irritative acceleration, but a lasting frequency in- 
dicates myocardial change. It may, in exceptional cases, be normal, 
or even slow (to 36), as a result of compression. There is no charac- 
teristic pulse; dicrotism is frequent; there may be the pulsus para- 
doxus (weakening or intermitting with each inspiration [Traube]). A 
very strong or water-hammer pulse may suggest underlying valvular 
disease. Irregularity is occasional, as is the pulsus differens and 
difference in the pupils. Lung compression is frequent. Bamberger 
observed a small area of compression, the size of a dollar, at the angle 
of the left scapula, where bronchial breathing, dulness (or tympany), 
and increased fremitus, are noticed; the compression clears up when 
the patient assumes the knee-chest posture (Pins). Pleural puncture 
excludes the possibility of fluid in doubtful cases, and the absence of 
crepitant rales excludes pneumonia. Bamberger's sign occurred in 
cases of hsemopericardium (Allbutt). There may be tympany (or 
dulness) under the left clavicle and to the left (and sometimes to the 
right) of the heart in cases where there is a fair-sized effusion. Ewart 
describes tubular breathing near the right mamma. 

Thrombosis of the innominate veins may result from compression. 
Walshe observed tracheal compression. The second pulmonic sound 
may be accentuated, which Warthin regards as an early sign. The 
second tone may be split (Skoda). Metallic heart tones may be due 
to an adjacent cavity, to pneumothorax, or to the stomach and intes- 
tines. A systolic non-valvular murmur over the aorta has been explained 
by pressure on, or inflammatory relaxation of, the vessels, thus inter- 
fering with their normal vibration. Organic valvular or accidental 
murmurs may occur. 

Diagnosis. — Differentiation rests upon (1) the friction, and (2) the 
dulness, or on both, with constant attention to (3) the apex beat. Sub- 
division into types, such as acute or chronic, fibrinous, serofibrinous, 
seropurulent, purulent, ichorous, or hemorrhagic, is inadvisable, as 
puncture alone reveals the character of the exudate. Fibrin forma- 
tion and serous exudation usually coexist (Latham). 

1. The Pericardial Rub. — The pericardial rub is practically patho- 
gnomonic of pericarditis (Von Dusch). (It has resulted on rare occa- 
sions in cholera from tissue dryness, in tubercles, cancer, soldier's spots, 
hemorrhage, hypertrophied heart, and inflammation of the diaphragm 



384 DISEASES OF THE CIRCULATION 

or of the peritoneum, in which cases the heart beats against the in- 
flamed surface.) 

(a) In distinguishing it from endocardial murmurs, the acoustic qual- 
ity, superficial character, lack of rhythmic precision, variability, slight 
propagation, palpatory difference in the rub, the basal location, and in- 
crease of the pericardial friction by pressure or inspiration are most 
decisive. Sometimes pericardial friction obscures a concomitant or 
preexisting endocarditic bruit. The distinction is sometimes difficult, 
between an aortic to-and-fro murmur and pericardial friction. 
Valsalva's experiment — i. e., a long inspiration with closed glottis fol- 
lowed by expiration with tense abdominal muscles — intensifies 
pericardial friction and decreases endocardial murmurs. Bearing in 
mind the great frequency with which pericarditis is a complication 
(or coordinate phenomenon) of endocarditis, this special point neces- 
sitates reserve in the prognosis, because the valvular disease remains 
after the pericarditis subsides. 

(b) It must be differentiated from pleuropericardial friction (pseudo- 
or extrapericardial) originating in the inflamed pleura, where friction 
depends not only on respiration, but also on the heart's action. The 
usual distinction lies (i) in the close connection of the pericardial rub 
with the cardiac activity, which persists during expiration, and (ii) in 
the location of the pleuropericardial friction in the sinus mediastino- 
costalis (along the lingual lobe), in its intimate relation to respiration 
and in its usual cessation, either at extreme inspiration or expiration 
(Stokes, Addison). This method of differentiation is not infallible, 
for inspiration also augments true pericardial friction, which is, 
however, increased by bending forward. Valsalva's test (v. s.) is also 
useful. Pericardial friction toward the base or sternum is less often 
confused with pleural friction. Rosenbach finds differentiation most 
difficult when the basal vessels come in contact with a tuberculous 
cavity or pneumonia. 

(c) Differentiation from precordial emphysema is possible on account 
of the crackling sounds of interstitial emphysema (air) in the anterior 
mediastinum. The sounds resemble rales, but are closely associated 
with the heart's action and are often metallic. The condition of the 
heart tones is decisive. 

(d) Differentiation from pericardial splashing (see Pneumoperi- 
cardium). 

(e) Crepitant rales are easily differentiated. 

2. The Dulness of Pericardial Exudation, — typically pyriform or trian- 
gular, — is modified by pleural or pericardial adhesions, and by pulmo- 
nary emphysema. The relative cardiac dulness (which may be markedly 
increased) should be considered rather than the absolute dulness 
(which is often little altered). 

(a) Hydro pericardium and effusive pericarditis may be confused, 
because stasis with hydrops pericardii may intervene in pericarditis, 
the friction may be absent or disappear, and fever may be lacking 
(chronic pericarditis). Hydropericardium shows its etiological fac- 



PERICARDITIS WITH EFFUSION 385 

tors. These are local pericardial changes or a general cause for hy- 
drops, and are differentiated by previous anasarca or hydrothorax, 
which almost always develops first, by lower dulness, by resorp- 
tion under digitalis and purges, by absence of friction, and by para- 
centesis, which reveals the usual differences between exudates and 
transudates in their opacity, specific gravity, and percentage of 
albumin (see Pleurisy). 

(b) Hcemopericardium, resulting from trauma and rupture of a coro- 
nary artery, or from ventricular or aneurysmal rupture, is usually sud- 
den, is attended by syncope, and blood is removed by puncture. 

(c) Pneumopericardium (q.v.). (d) From cardiac dilatation the differ- 
entiation may be most difficult, especially when there is dilatation plus 
hydrops pericardii, in which case drastics, digitalis, friction, the history 
and evolution only, may decide. In dilatation the dulness is 
rarely triangular but rather is increased laterally, the shock-like im- 
pulse of the heart is more marked and often contrasts sharply with the 
weak radial pulse, compression of the lung is much more uncommon, and 
the heart tones are more clear and "snappy." The very distinctive re- 
lation between the apex and the outer dulness to the left is rarely fallible 
(v. s.). If the pulse is strong and the apex weak, pericarditis is present 
(with, of course, the typical dulness) ; but compression or weakness of 
the heart in pericarditis necessitates a weak, rapid pulse. In both af- 
fections the heart's dulness is increased by leaning forward; but this 
may clearly demonstrate the apex within the dulness of the exudate. 
When the patient lies on his right side the apex in pericardial effusion 
becomes visible (Rosenbach), which does not obtain in cases of en- 
larged heart. In children the diagnosis of pericardial effusion is often 
made incorrectly ; the dulness is equally often a dilatation . (e) When there 
is retraction of the left lung away from the heart, the diaphragm is high, 
the apex and outer cardiac dulness coincide, the spleen is high, the pul- 
monary artery is exposed, and the proper signs of pulmonary contrac- 
tion are elicited (Leube). (/) In cases of mediastinal tumor the dulness 
is irregular; there is no variation of dulness on postural change; the 
signs of increased conduction and bronchial breathing are noted with 
the absence of the cardinal signs of pericarditis, (g) From aneurysm 
the differentiation is usually possible, as well as from marginal infil- 
tration of the lung; callous pleura, encapsulated pleurisy, superabun- 
dant fat (Walshe); and anterior mediastinitis (usually with friction, 
but with more vertically elongated dulness). 

Diagnosis of the Character of the Exudate. — The fluid is serofibrin- 
ous in rheumatism; ichorous in perforation from hollow viscera; hem- 
orrhagic in scurvy, carcinoma, tuberculosis, hemorrhagic exanthemata, 
and alcoholism; and purulent in sepsis and empyema. Paracentesis 
is the only certain test. Tuberculous pericarditis, even in clearly 
tuberculous cases, can be diagnosticated positively only by detection of 
tubercle bacilli in the aspirated exudate; a chronic pericarditis is prob- 
ably tuberculous. In children 30 per cent, of pericarditides are suppur- 
ative and 17 per cent, are tuberculous (Baginsky). 

25 



386 DISEASES OF THE CIRCULATION 

Course. — The clinical course is variable; exudation may follow the 
friction in a short time or only after many days. The exudate may be 
rapidly absorbed in a few days or may endure for weeks or months. 
The average duration is one or two weeks. In convalescence the heart 
may long remain irritable on exertion. 

Prognosis. — The prognosis depends largely upon the physiological 
resistance, the causal disease, and the character and quantity of the 
fluid; it is usually good in rheumatic and serofibrinous cases. Septic, 
purulent, putrid, or hemorrhagic types, are more serious. The pneu- 
mococcic form is fatal in 50 to 75 per cent. Pericarditis is most danger- 
ous in the very young or aged. Death may be rapid in hemorrhagic 
cases; it usually is due to cardiac exhaustion, especially in cases of 
long-standing, and results from myocarditis rather than from simple 
pressure. The prognosis is more favorable in men than in women and 
children. 

Treatment. — 1. The hygienic treatment should be managed as it is 
in any acute infection with cardiac involvement. 

2. Absolute rest in bed is indicated, in order to spare the heart, 
even during convalescence. The patient should never be allowed to 
sit up or leave the bed, even to urinate or defecate, for severe or fatal 
syncope may follow the effort. 

3. Laxatives should be given, for constipation per se may increase 
the heart action, and difficult bowel movements, with the attendant 
straining, weaken or paralyze the heart. Sod. phosphate 3 SS - to ij, is 
an excellent laxative. 

4. The diet should be light or fluid, and tea and coffee, which excite 
the heart, should be avoided. Alcohol may be given when a septic 
process prevails or when the patient is accustomed to its regular 
use. 

5. Local antiphlogistic measures should be employed. An ample ice- 
bag upon the precordia quiets and regulates the heart-rate, and 
relieves palpitation and pain. The author believes that it is often a 
better cardiant and sedative than drugs. Leeches may be applied 
after drawing some blood by small scratches over the heart; their 
action is regulated by applying salt, which causes them to release their 
hold. A Spanish-fly blister, as large as the hand, often not only relieves 
pain but stimulates resorption. It must be dressed carefully with 
weak carbolic salve and gauze. Cupping may be of service. 

6. The cause should be treated. Therapy of the underlying disease 
is indicated, — such as the use of salicylates, in the rheumatic form. 

7. Heart stimulation is indicated when the pulse is irregular, fast, 
or small, for this is due to early cardiac irritation or to later mechanical 
compression of the heart and lungs by the exudate (see Treatment 
of Valvular Diseases) . Alcohol should frequently be given (see 
Typhoid Fever and Pneumonia for its action and indications). 
Strychnia, coffee, and camphor, operate more quickly than digitalis; 
they can also be used to follow up its action. Cardiac depressants, 
such as aconite, are to be carefully avoided. 



ADHESIVE PERICARDITIS 387 

8. Treatment of the fever depends on the basic disease. Hydro- 
therapy is preferable to the use of antipyretics. 

9. Compression symptoms, such as dyspnoea, insomnia, and vomit- 
ing, when mild in degree or not of long standing, are met by the 
judicious use of morphine hypodermatically. Tardy resorption of 
large exudates or sudden or severe symptoms therefrom necessitate 
tapping of the pericardial sac, under the general precautions observed 
in pleural aspiration. The puncture is made in the fifth left (or right) 
interspace about an inch from the sternum, where the sac is not covered 
by the pleura. Care and gentleness in passing the trocar enable us 
to feel the giving way of the parietal pericardium and to avoid cardiac 
trauma. Removal of but a small quantity frequently provokes absorp- 
tion by relaxation of the vessels in the tense pericardium, although 
results are sometimes disappointing. Sudden or extreme cardiac embar- 
rassment may necessitate free venesection. 

10. Special indications in various forms of the disease are encoun- 
tered. Ergot is indicated in the hemorrhagic type, alcohol in drinkers, 
and care of the kidneys in nephritis. 

11. Delayed absorption is treated by potassium iodide gr. x to xx, by 
diuretin 60 to 90 gr. per diem, and by small doses of calomel followed 
by salines. Hot packs, alcohol sweats, and pilocarpine, should be most 
cautiously employed or entirely avoided, for with their use symptoms of 
collapse occur quite frequently. 

12. Early pericardiotomy is indicated in suppurative or putrid 
forms when the causal disease permits it. About one-half of the cases 
recover. 

Adhesive Pericarditis. 

(Pericardial Concretion [Synechia]; Cicatricial [Callous] Mediastino- 

Pericarditis.) 

Though pericarditis may resolve completely, local adhesions within 
the sac or more extensive bands to the chest wall, pleura, spine or other 
structures, are frequent. They develop in 41 per cent, of cases of peri- 
carditis (Breitung) and are found in 6 per cent, of autopsies (Leudet). 
In one group of cases, complete obliteration of the sac may occur with 
absolute clinical latency ; the heart may beat itself loose from fresh or 
lax adhesions, especially when they are located about the apex. 
In a second group, there are undistinctive evidences of cardiac 
insufficiency. In a third series, distinctive physical signs exist. 
Adhesions most frequently follow serofibrinous pericarditis. A clear 
history or the actual observation of a previous pericarditis is one of the 
strongest points in the diagnosis. 

Symptoms. — 1. Cardiac insufficiency is caused by pressure on the 
coronary arteries, by myocardial fibrosis and degeneration, but more 
often by dilatation or atrophy. Though severe heart symptoms in 
advanced life without valvular disease are indicative of myocardial 



388 DISEASES OF THE CIRCULATIOX 

degeneration, in the young they suggest pericardial adhesions 
(Wilks). Evident failure of the right ventricle without valvular, 
renal, or pulmonary disease, or with sudden break in compensation 
in the usual valvular lesions, directs attention to possible pericardial 
adhesions. Weiss and Pick have called attention to an isolated ascites 
which is not found in simple cardiac incompetency, but is usually 
associated with large liver and somtimes with fibrous peritonitis; it is 
probably due to the extension of inflammation along the vessels from 
the pericardium to the peritoneum. Sudden death is sometimes due 
to pericardial synechia? (Aran). 

2. Systolic retraction of the interspaces at the apex may occur 
even with slight basal adhesions which hinder the systolic descent of 
the heart, while diffuse adhesions other than basal often produce no 
symptoms. It is especially significant when the normal systolic pro- 
trusion has been gradually replaced after pericarditis by systolic 
retraction, for retraction of the apex also occurs in other conditions. 
Systolic retraction is merely an expression of impaired locomotion of 
the heart and of lack of space at the apex. It is best seen on deep in- 
spiration and disappears when the heart grows weak. Retraction of 
the apex can be seen, and can also be felt. 

3. Retraction (not merely of the apex but) of the sternum, epi- 
gastrium (Oppolzer), diaphragm, and lower chest wall, may be observed 
when adhesions also exist outside of the pericardium in the mediasti- 
num (Skoda) ; it is indicative of indurative mediastinitis, which attaches 
the heart anteriorly to the chest wall and posteriorly to the spine, and 
necessitates retraction unless cardiac weakness develops. Broadbent's 
sign is a systolic retraction of the eleventh and twelfth ribs posteriorly 
and on the left side. 

4. The diastolic recoil (Friedreich), due to rebound of the retracted 
diaphragm and chest wall, is recognized by palpation and by ausculta- 
tion as a dull vibration which may cause the second tone to appear 
doubled. 

5. Diastolic collapse of the cervical veins (Skoda) is of great diag- 
nostic value, and is due to their aspiration by the heart; it is some- 
times dicrotic and may produce diastolic pallor of the face. The cervical 
veins often swell with the systole. 

6. The pulsus paradoxus (a pulse intermitting with inspiration) 
strongly suggests cicatricial mediastinopericarditis, particularly when 

Fig. 21. 




B E 

Pulsus paradoxus (Kussmaul); E, beginning of expiration, and J, of inspiration. 

observed with the signs previously mentioned. It is observed to a 
moderate extent physiologically and is sometimes seen in other condi- 
tions which lessen the entrance of air into the lungs or render the heart 
sensitive, especially in myocarditis (Riegel). It is due in mediastino- 



ADHESIVE PERICARDITIS 389 

pericarditis to inspiratory stretching of the great vessels by well- 
attached mediastinal adhesions, which shuts off the blood supply to 
the extremities. It is a mediastinal symptom, and occurs (a) when the 
arterial system is poorly filled, and hence is more important when the 
heart tones are normal or stronger than normal, and (b) when the 
return venous flow is retarded. Schreiber holds it pathognomonic when 
(i) it appears without forced inspiration, (ii) when the radial and all 
other pulses are completely suspended by inspiration, (iii) when the 
heart's action is regular and (iv) when it is combined with inspiratory 
swelling of the cervical veins (v. i.). Struempell observed slowing of 
the pulse during inspiration. This was explained by him as irritation 
of the vagus by the mediastinal connective tissue. 

7. Inspiratory swelling of the neck veins (Kussmaul), which nor- 
mally collapse during inspiration, is due to the same mechanism 
as the pulsus paradoxus. Inspiration stretches the mediastinal bands, 
which constrict the large venous trunks and interrupt the return 
venous flow. Cyanosis may occur with each inspiration. 

8. Other signs are fixation of the heart by adhesions, which gives 
no change of dulness by change of posture (von Dusch); absence of 
respiratory excursion over the heart; decrease of Traube's semilunar 
space by pleural adhesions (Jaccoud); decreased movement of the 
left half of the epigastrium (diaphragmatic adhesion to heart) ; expira- 
tory weakening of the apex by pleural adhesions (Tuczek-Riegel); 
weak right heart with no accentuation of second pulmonic tone; loud, 
even musical, murmurs, especially in the aged; systolic emptying of the 
veins of the thorax due to systolic dilatation of the internal mammary 
veins (Broadbent); a rumbling presystolic murmur (Fischer, Hale 
White) at the apex, especially in children, without signs of mitral 
stenosis; precordial creaking (Perez) when the patient moves the arm; 
and other mediastinal symptoms, e.g., left recurrent laryngeal paralysis, 
venous thrombosis in arm, etc. 

Diagnosis. — In the diagnosis, two groups of symptoms are observed: 
first, the myocardial (dilatation, hypertrophy, relative tricuspid in- 
sufficiency); and second, the mediastinal (pulsus paradoxus, etc.) 
(See Pick's Pericardiac Pseudocirrhosis, under Diagnosis of 
Hepatic Cirrhosis.) 

Prognosis. — The heart must suffer to a varying extent when its 
movement is impaired, whence the prognosis depends upon the condi- 
tion of the myocardium. 

Treatment. — The treatment is identical with that of valvular 
disease (q. v.) or of m} ocardial insufficiency in general. Brauer advo- 
cates surgical solution of the adhesions (cardiolysis) ; about a dozen 
operations are reported. The heart muscle must, however, be in good 
condition to warrant surgical interference. 



390 DISEASES OF THE CIRCULATION 



PNEUMOPERICARDIUM. 

The presence of gas or air in the pericardium is very infrequent; 
James (1904) could collect but 38 cases. 

Etiology. — It results (a) from trauma, such as perforating wounds; 
(6) from perforative processes from cavities or viscera containing air or 
gas, such as pulmonary cavities; from gangrene, pneumothorax, 
oesophageal ulcers or neoplasms; gastric ulcer, liver abscesses, or 
caseated bronchial glands. There is almost always fluid, which may be 
ichorous, hemorrhagic, purulent (pyopneumopericardium), or more 
rarely serous (hydropneumopericardium). (c) Exceptional instances 
of spontaneous gas development without solution of continuity have 
been observed, due to the Bacillus aerogenes encapsulatus. 

Diagnosis. — On inspection, there is precordial bulging and absence 
of the apex beat, though this may reappear upon leaning forward. On 
palpation, the vocal fremitus about the heart, and the apex beat are 
gone, friction and occasionally splashing, churning, gurgling sounds 
may be felt. On percussion, when the patient is sitting, a tympanitic 
or even metallic note is obtained above or indeed over the entire 
heart, especially when percussion is made with the plessimeter and 
the hard part of the percussion hammer or the finger-nail. Fluid 
is usually detected when the patient is in the sitting or lateral 
decubitus. 

The tympanitic note heard above, and the fluid below, is present only 
when no adhesions are present and varies during the systole and dias- 
tole; it becomes higher in the erect posture and varies with the amount 
of exudation. The change in note on change of posture and the con- 
dition of the apex depend upon hydrostatic laws, as is the case in 
pneumothorax. The lung is compressed. On auscultation, the heart 
tones vary with the fluid, being loud if there is no great effusion, and 
usually metallic or musical, like a sound from a zither. The same is 
true of the quality of the friction (for pericarditis is almost invariably 
present). The tones, the metallic tinkling or splashing, the falling- 
drop sound, the mill-wheel churning and succussion, may be heard at 
a distance. They may keep the patient awake and may be heard in an 
adjacent room, as in cases of Stokes, Laennec, and Graves. 

Differentiation is required from cavities or encapsulated pyopneu- 
mothorax near the heart. Consideration of the heart, dulness, even 
though it be dislocated, and of the apex beat, renders the diagnosis easy. 
Confusion with distention of the stomach, which imparts a metallic 
note to the heart tones, is similarly excluded. 

Prognosis. — Death occurs in 70 per cent, of the cases and usually 
results within two weeks, from the causal disease and from cardiac 
insufficiency. Recovery is most probable in the traumatic cases. 

Treatment. — Treatment is the same as in pericarditis. Puncture to 
void the gas, and operation for putrid or purulent processes, are indi- 
cated. 



H&MOPERICARDIUM 391 



HYDROPERICARDIUM (HYDROPS PERICARDII.) 

Hydropericardium is always secondary to (a) circulatory disturbances, 
such as heart or pulmonary lesions, or local obstruction in the peri- 
cardial veins; the latter is infrequent; or (b) cachectic conditions pro- 
ducing blood alteration and transudation, such as Bright's disease, or 
carcinoma. 

Symptoms. — They are much the same as in pericarditis, except that 
friction is absent. The heart region is sometimes prominent, the apex 
beat is lost, the heart tones are distant, the fluid changes with change of 
posture, the dulness is clearly triangular or trapezoidal since no adhe- 
sions exist. In most autopsies a small amount of fluid is found which 
transudes during the death agony or after death. In hydropericardium, 
the fluid is yellow-green, and is sometimes slightly tinged with blood. 
Cholestearin crystals are sometimes found. Evidences of inflammation 
are absent. The fluid is alkaline, contains some albumin, sugar, and 
urea, and is of low specific gravity. Chyle-like effusions (chyloperi- 
cardium) are very rarely seen. 

Diagnosis. — The signs of fluid are the same as they are in pericardi- 
tis (q. v. for differentiation), but there is no temperature, tenderness, 
nor friction murmur. Dilatation of the heart causes the most frequent 
diagnostic confusion and is differentiated as it is in pericarditis. The 
etiological diagnosis is most important, such as finding a cardiac lesion 
in the first and renal lesion in the second group. 

Prognosis and Treatment. — The prognosis and treatment depend 
wholly on the cause. Cardiac stimulants, blisters over the heart, lax- 
atives, etc., are indicated. 

H£!MOPERICARDIUM. 

Blood tinges the exudate in certain forms of pericarditis. A large 
quantity of blood may escape into the sac in trauma of the heart or 
of the sac, rupture of the heart (q. v.) or of aneurysms (q. v.). 

The symptoms and physical signs relate to (a) the acute anwmia, with 
pallor, syncope, and rapid pulse, which usually ends, in a few hours or 
possibly a few days, in death; (b) signs of fluid in the pericardial sac. 
The prognosis is favorable only in the traumatic cases. The treatment 
is expectant; the heart should be stimulated and salt solution should 
be infused. 



392 DISEASES OF THE CIRCULATION 

DISEASES OF THE ENDOCAEDIUM. 

ENDOCARDITIS. 

Definition. — Inflammation of the endocardium. Its clinical impor- 
tance attaches to the fact that the valves of the heart are involved. 
Two main varieties are distinguished, the acute and the chronic. 

I. Acute Endocarditis. 

This is practically always a secondary, general disease, and is mycotic 
in origin (excepting atheromatous endocarditis). Two main clinical 
varieties are described : (a) Malignant or ulcerative endocarditis, and 
(b) simple or verrucose endocarditis. They differ only in degree. 
Litten divides endocarditis into (a) the benign forms produced by 
rheumatism, chorea, gonorrhoea, scarlatina, measles, variola, typhoid, 
diphtheria, pneumonia, tuberculosis, grippe, and traumatism; and (b) 
malignant, (i) non-suppurative, caused by rheumatism, chorea, or 
gonorrhoea, and (ii) suppurative or septicopysemic. 

(A). Malignant Endocarditis. 

This variety is also known as ulcerative or septic. 

Etiology. — The heart lesion is either (1) secondary to some clearly 
causal infection or disease, as furuncles, dysentery, typhoid, empyema, 
abscess or gangrene of the lungs, pneumonia, tuberculous foci with 
mixed infections, hepatic abscess, suppuration of the gall bladder, 
pylephlebitis, pyonephrosis, cystitis, gonorrhoea, calculi, diseases of the 
prostate, puerperal or other infections of the female genitalia, middle- 
ear disease, and to osteomyelitis or such specific infections as scar- 
latina or more rarely typhoid, rheumatism, diphtheria, smallpox, or 
malaria; or (2) crypto genetic, when the causal infection is not apparent. 
Care in examination and at autopsy usually reveals an obscure cause 
and thus decreases the number of these cases. 

The disease is more common in women than in men, even excluding 
the cases resulting from puerperal infections; it is most frequent 
between the years of twenty and forty. Its frequency is 2 per one 
thousand patients. Seventy-five per cent, of cases develop upon an old 
valvular lesion by which the physiological resistance is lessened, or in 
a hypoplastic aorta. The literature contains 11 cases of ulcerative 
endocarditis involving a patent ductus Botalli (Hart, 1904). 

Pathology. — Malignant endocarditis most often involves the left heart, 
because it is far more frequently the seat of previous lesions and its 
arterial blood favors the growth of microorganisms, although the 
right heart is involved more frequently than it is in other types of 



MALIGNANT ENDOCARDITIS 393 

endocarditis. Lenhartz found the left heart affected in 86 per cent., 
the right in 12 per cent., and both sides in 2 per cent., of his cases. 

Though the process may involve the walls (parietal or mural endo- 
carditis), it most frequently attacks the valves (valvular endocarditis), 
which are often already indurated by previous simple endocarditis, 
are most washed by the circulating blood, and are subject to greater 
mechanical activity. The endocardium becomes opaque, and irregular 
deficits occur on the under surface of the aortic or the auricular 
surface of the mitral valves; and later there is a grayish deposit sur- 
rounded by some swelling and injection of the endothelial coat. Exu- 
dation is abundant on the mitral valves, but is late or scanty on the 
less vascular aortic or pulmonary valves. Thrombi and excrescences 
develop on the erosions, whose removal discloses subjacent ulceration. 
The thrombi consist of lamellated fibrin and bacteria. The vegetations 
may attain the size of a walnut and often extend from one valve to 
another by contact infection. 

Some thrombi are apparently purely mechanical deposits of fibrin, 
but genuine endocarditis is probably always mycotic. Heiberg first 
found microorganisms (1869) and Weichselbaum first obtained pure 
cultures. 

Efforts to classify endocarditis by the bacteriological findings are 
more or less impracticable. The following bacteria have been found: 
Streptococcus, staphylococcus, pneumococcus, and less frequently the 
gonococcus, colon, diphtheria, influenza, tubercle, and typhoid bacillus, 
meningococcus, a long bacillus (Alchame), Bacillus endocarditidis 
griseus and encapsulatus, Micrococcus endocarditidis rugatus, Bacillus 
pyogenes fcetidus, Bacillus fcetidus immobilis, and Bacillus pyocya- 
neus. The same organism may produce either the benign or malig- 
nant form. 

Bacteria may cause the endocarditis or may only be deposited 
from the blood upon vegetations of other origin, for mixed infections 
are common. Experimental endocarditis (Wyssokowitch, Ribbert) 
has been produced by inoculations of various organisms, usually 
after wounding the valves by a sound introduced through the cer- 
vical vessels, but also without trauma. The pyogenic organisms are 
said to attack more frequently the mitral, and the pneumococcus 
rather selects the aortic valves. The mitral valves in general are 
more often involved than are the aortic. The process may invade the 
aorta, the pulmonary artery, or the lung. Destructive changes by 
ulceration through one leaf of the valve may produce acute valvular 
aneurysm, which, when aortic, projects toward the ventricle, and when 
mitral, projects toward the auricle. If the necrosis destroys both 
lamellae of the valve, the perforation leads to valvular insufficiency. 
Ulceration of the chordae tendinese, or papillary muscles, also produces 
valvular insufficiency; necrosis of the parietes results in a "heart 
ulcer," which sometimes leads to communication between the ven- 
tricles, or to rupture of the heart. Dislodgment of tissue particles, 
thrombi, or bacteria, occurs frequently, and usually in the arterial 



394 DISEASES OF THE CIRCULATION 

circuit. The effects vary with the location of the infarct (See Symptom- 
atology) and with the character of the microbes; i. e., they act 
mechanically and infectively. Streptococci are said to produce anemic 
infarcts, while staphylococci result in suppuration. Pathological 
changes in other organs are those of (a) general sepsis, such as par- 
enchymatous degeneration, or splenic tumor, (b) embolism, mechan- 
ical or infective, (c) stasis when the heart fails, and (d) the primary 
disease. 

Symptoms. — The clinical features vary to such an extent, according 
to the basic disease, the special visceral involvement by embolism 
and the virulence of the microorganisms, that a general description 
is impossible. The onset may be violent or most insidious during 
convalescence from the primary disease. The autopsy findings in the 
latent cases may be surprising, as, for example, the discovery of a 
mural gonorrhceal endocarditis in a case which clinically resembled 
septicopyemia. In the majority of cases, the septic element prevails. 
The various types, somewhat artificial though convenient for descrip- 
tion, are: 

1. The Typhoid Form. — The toxemic symptoms, such as apathy, 
delirium, dry tongue, distended abdomen, splenic tumor, diarrhoea, 
and albuminuria, are suggestive of typhoid. The resemblance may 
be heightened by hemorrhage of the bowels, rose-like spots, and the 
response of the urine to the diazo reaction. Dilatation of the right 
heart, and cardiac murmurs, so important in endocarditis, are not 
uncommon in typhoid. Obvious embolism helps to establish the 
diagnosis. The pneumococcus is often the cause of this type. In 
the skin embolism appears as spots with a white or yellow centre and 
hemorrhagic periphery, or as pemphigus, gangrene, or suppurative 
foci. Analogous areas may be seen in the upper air-passages. Infarcts 
may sometimes occur in the conjunctiva, but in the retina simple spots 
of hemorrhage or actual infarcts with yellow centres are frequently 
detected. The entire eyeball may suppurate. The frequent splenic 
infarction is characterized by sudden pain, tenderness, enlargement, 
and sometimes perisplenitic friction. Embolism is often accompanied 
by fever, chill, and vomiting. Renal infarction is very frequent, and 
is attended by pain in the loins, hematuria, albuminuria, and some- 
times anuria or dysuria. Staphylococci may be found in renal ab- 
scesses. Severe nephritis is common. Cerebral embolism usually 
occurs in the left Sylvian artery, and results in the usual shock and 
hemiplegia with aphasia. Pulmonary infarcts are caused by lesions 
of the right heart or by auricular thrombi, and occasion sudden pleu- 
ritic pain, dyspncea, hemoptoe, temperature, and possibly a small area 
of crepitant rales, pleural friction, or consolidation. Embolism also 
occurs in the liver, in the mesenteric artery (with enterorrhagia and 
peritonitic symptoms), in the muscles and joints, testes, and parotid; 
in the heart, and the various mucosae; in the meninges, pleurae, peri- 
cardium, peritoneum, and in the peripheral arteries, sometimes causing 
gangrene, or embolic aneurysm. 



MALIGNANT ENDOCARDITIS 395 

The course may be peracute (two to four days), acute (a few weeks), 
or chronic (several months). Death occurs from the typhoid state, 
from embolism, or from cardiac failure. 

2. The Septic or Intermittent Type. — This form has an irregular 
fever-curve, with chills and drenching sweats; and the spleen is en- 
larged. Heart symptoms may be absent or indeterminate, the mod- 
erate relaxation of the right heart and the murmur being often called 
functional. The paroxysms are more irregular than in malaria and 
•no response to quinine is obtained. The streptococcus is often causal. 
Cardiac findings, embolism, or clearly septic manifestations, may estab- 
lish the diagnosis. The course is usually several weeks but may cover 
months. 

3. The Visceral Forms. — These forms embrace the cases in which 
some one organ is especially involved. In the cardiac form, anaemia 
exists and the heart murmur seems accidental, until a typical valvular 
lesion develops, or, if one already be present from older valvular dis- 
ease, until another appears as a diastolic following a systolic murmur. 
The diagnosis may be difficult even when chronic valvular disease is 
present. In the cerebral form, meningitis, apoplexy, coma, or psychoses, 
may dominate the clinical picture. The symptoms referable to any 
organ which is the seat of embolism (lung pericardium, etc.), may 
seem to indicate a primary disease. In this way acute yellow atrophy, 
cholera, etc., have been incorrectly diagnosticated. 

Special Symptoms. — (1) All types of fever, from intermittent to 
continuous, have been noted, although it may be absent for a long 
time or may not develop at all. (2) The heart is always somewhat 
disturbed in its action, cardiac unrest being common. Its action is 
usually more frequent, but is quite variable, now being rapid, again 
slow, and often irregular. The heart seems to beat harder and the 
pulse may throb although the irritable overaction is attended by low 
arterial tension. The heart tones are dulled. Palpitation is frequent. 
Cyanosis is not common. (3) Respiration is always increased, from 
toxsemic centric stimulation, or from pain or respiratory complica- 
tions (septic pneumonia, infarcts, pleurisy, pneumothorax, or gan- 
grene). (4) The digestive tract may .be affected. Anorexia is not 
invariable. Nausea, vomiting, and diarrhoea, may occur from the gen- 
eral sepsis. Embolism has been mentioned. The liver is enlarged, 
may be tender, or may be the seat of friction. Icterus may be marked, 
is ominous and is referable to duodenal catarrh or to oversecretion of 
bile (polycholia). (5) The spleen is almost always palpably enlarged 
from sepsis or embolism. (6) The urine shows evidences of the 
sepsis or stasis by albuminuria with or without cylindruria, of the 
"blood dissolution, " and of the embolism by hsematuria. Malignant 
endocarditis may run a course similar to that of subacute nephritis, 
which is present in 33 per cent, of all cases of the ulcerative type. 

(7) The nervous system may be irritated or dulled by the sepsis toxins, 
or embolic lesions, such as meningitis or encephalitis, may intervene. 

(8) The motor system is often affected. The muscles are frequently 



396 DISEASES OF THE CIRCULATION 

tender and actually inflamed, and may undergo suppuration. The 
bones are often tender and the joints tender or swollen, although the 
swelling is more frequently peri-articular than intra-articular. Bac- 
teria are seldom found, and this may heighten the resemblance to 
rheumatism. (9) The skin may be the seat of embolism (v. s.) or 
of eruptions, such as sudamina, urticaria, erythema, purpura, poly- 
morphous septic rashes from bacteria or their products in the circu- 
lation. Bullae, gangrene, phlegmons, or bed sores, are also observed. 
(10) The blood is also affected. There is usually marked anaemia;, 
when there are no heart findings, the anaemia and splenic tumor 
have been confused with pseudoleukemia. The leukocytes are often 
but not always increased. Bacteria may be cultivated from the blood 
by modern methods of inoculation from a large quantity of blood in 
much bouillon. The latter and other points are considered under 
Septicopyemia (q. v.). 

Bacteriological Forms. — (a) Streptococcic Endocarditis. — The ordi- 
nary streptococcus is the usual cause of rapidly fatal and of chronic 
ulcerative endocarditis, both with severe repeated chills and high 
irregular fever. Acute cases may result from the small streptococcus, 
which is said to usually cause moderate fever, (b) Staphylococcic 
endocarditis is less frequent. The course is nearly always acute 
and is attended by high fever, pustules in the skin, dissemin- 
ated hemorrhages, and septic infarcts, especially in the kidneys. 
(c) Pneumococcic endocarditis (see Pneumonia) is usually acute; 
frequently follows pneumonia, less often cholecystitis; begins with 
gradual fever rise associated commonly with chills; and is often at- 
tended by suppurative meningitis. (d) Gonococcic endocarditis 
(Ricord, 1847) may result from Neisser's coccus or from mixed 
infection with the strepto-, staphylo-, or pneumococcus. Cases of 
recovery are instanced. 

Diagnosis. — Bamberger's remark of half a century ago still holds: 
"The diagnosis of acute endocarditis is seldom easy, is usually difficult, 
and often impossible. " Unless there are physical changes in the heart, 
the diagnosis is only presumptive. A proper etiology, temperature, 
signs of cardiac insufficiency, such as blue nails or cold extremities, 
irregular weak pulse with apparently strong, cardiac shock and 
dilatation are very suggestive and may be confirmed by continued 
observation, by embolism, by change in the valvular murmur, and by 
blood-cultures. Actual hypertrophy of the heart not only requires time 
for development but adequate nutrition, of which the disease seldom 
admits. In 37 per cent, of cases, the heart is negative, in 44 per cent, 
the murmur is systolic and in 5 per cent, diastolic. Absolute certainty 
rests upon our ability to diagnosticate by physical signs, the presence 
of a mitral regurgitation (q. v.) which is the most frequent form, or 
of an aortic regurgitation (q.v.) plus the signs of sepsis of which the 
disease is a part ("arterial pyaemia"). The valvular murmur may dis- 
appear after embolism. Confusion with typhoid or malaria is possible 
(see Typhoid, differential table). 



(YERICOSE OR) BENIGN ENDOCARDITIS 397 

Diastolic murmurs are very rarely functional, and their appearance 
is therefore especially suggestive. Myocarditis may produce a systolic 
murmur, but is usually attended by marked early muscular insuffi- 
ciency, weak-heart shock and irregular pulse, weak systolic murmur 
and a moderately accentuated second pulmonary tone. 

Recurrent endocarditis shows not only the fever and other symptoms 
caused by the fresh lesions, but also the hypertrophy of the older 
valvular lesion. An aortic diastolic or a mitral presystolic murmur 
is more likely to indicate an old lesion. With repeated examinations, 
fresh murmurs may be heard in addition to the old ones. 

Prognosis. — The prognosis is almost always unfavorable; Herrick 
(1902) collected 22 cases of recovery. It depends on the strength of 
the heart, the bacteriology, the number of infarcts and their location, 
the variability of the heart murmurs (which may entail danger of 
embolism), and the intensity of the sepsis. Recovery from the gonor- 
rhceal form is relatively frequent. Musical murmurs with fever are 
usually regarded as ominous. Apparently light cases of endocarditis 
may become severe. The course may be rapid or severe; of but a 
few days duration; or it may have a slower evolution of even a year 
and a quarter. 

Treatment. — (See Benign Endocarditis and Septicopyemia.) 



(B). (Verrtjcose or) Benign Endocarditis. 

This variety is more frequent (1.5 per cent, of clinical cases) and 
is always secondary. (See general prefatory remarks to Ulcerative 
Endocarditis.) 

Etiology. — (a) Rheumatism (q. v.) is the most frequent cause, and 
60 to 85 per cent, of the cases can be referred to it. Twenty per cent, or 
more of cases of rheumatism suffer from endocarditis. It occurs in 
the more severe rheumatic cases. In children it is very frequent, 
for in them the heart "resembles an articulation. " Muscular rheu- 
matism, angina, or erythema nodosum, may occasion endocarditis. 
Chronic rheumatism predisposes to it. (b) Chorea is frequently com- 
plicated by endocarditis (30 per cent, of clinical and 82 per cent, of 
fatal cases). By some writers chorea is considered rheumatic but the 
majority hold that it is only correlated, (c) Of other specific injec- 
tions, scarlatina ranks first, (10 per cent, of the cases becoming in- 
volved). Endocarditis is far more uncommon after typhoid, diphtheria, 
tonsillitis, measles, erysipelas, gonorrhoea, variola, grippe, tuberculosis, 
or parotitis, (d) Occasionally it is associated with trauma, burns, 
syphilis, cancer, Bright's disease, gout, or diabetes, (e) It is more 
common in males between the years of twenty and thirty. 

Pathology. — The vegetations are verrucose, wart-like, papular, or 
even pedunculated, are usually small, and occur at or above the lines 
of closure of the valves, whereby their function is interfered with and 
valvular insufficiency or stenosis results. At times the vegetations are 



398 DISEASES OF THE CIRCULATION 

cauliflower-like, or resemble condylomata. They are grayish, gelatin- 
ous, and transparent; they become whiter and firmer with age, and 
consist of two strata, the deeper being granulating endocardium and 
subendocardial tissue and the superficial layer consisting of thrombi 
from the coagulable elements of the blood. The signs of active inflam- 
mation, such as redness or swelling, are usually lacking, redness 
being sometimes confused with post-mortem imbibition of haemoglobin 
from the blood. Vegetations must not be confused with Albini's 
nodes, which are seen in infants and children. The vegetations are 
at an early stage, quite cellular from leukocytic exudation and tissue 
proliferation and usually contain bacteria (see Ulcerative Type). 
Becoming detached, the outgrowths form emboli and produce mechani- 
cal hemorrhagic or anaemic infarcts, not suppurative infarcts as in the 
ulcerative type. The fate of the vegetations is (a) embolism; (b) 
organization with the bare possibility of restoration to normal; (c) 
organization with valvular lesions resulting from retraction, and from 
induration and calcification; (d) being a place of slight resistance, 
recurrent endocarditis may be observed; (e) the intensity of the in- 
flammation may increase, leading to malignant endocarditis. 

Location. — As in the first type, the vegetations are largely in the 
left heart, because of its greater physiological activity and its arterial 
blood, although these same conditions in fcetal life predispose to endo- 
carditis of the right heart, either on the valves or on fcetal openings 
or defects. In general, the mitral valves are most affected (50 per cent, 
of the cases alone or 80 per cent, when combined with other lesions), 
next the aortic (13 per cent, alone or 40 per cent, when combined with 
other lesions), and far less frequently, the tricuspid, the pulmonary, 
and the walls of the heart, chordae or parietes — (1) wall of left, or (2) 
of right auricle, (3) of left or (4) of right ventricle. 

Symptoms. — The symptoms are not characteristic and a diagnosis 
is impossible or only presumptive unless the valves are considerably 
involved. Simple endocarditis therefore is found far more frequently 
at autopsy than at the bedside; i. e., it is very often latent. With such 
heart symptoms as increased rate or palpitation, it is difficult or im- 
possible to determine whether they are caused by a valvular lesion or 
a myocarditis, though the latter is the more likely cause. Systematic 
daily examination of the heart in such diseases as rheumatism may 
reveal the gradual involvement of the endocardium with moderate 
fever, and dyspnoea, cardiac unrest, oppression, palpitation, or insuffi- 
ciency. Pain is more often pleuritic or pericarditic. The diagnosis 
depends on the valvular bruit, which often follows muffling or irregu- 
larity of the cardiac sounds, and is still later followed by the signs of 
mitral or aortic insufficiency (q. v.). The infrequent diastolic mur- 
murs are more distinctive than the systolic, for they are rarely func- 
tional. Embolism is very distinctive, as it is in the first type, and is 
important mechanically rather than bacteriologically. It also occurs 
in parietal endocarditis; embolism may be so minute or undistinctive 
as to escape recognition. 



(VERRUCOSE OR) BENIGN ENDOCARDITIS 399 

Diagnosis. — Conservatism in making the diagnosis is necessary, 
because acute benign endocarditis is much too often diagnosticated. 
The murmurs are mistaken for functional murmurs accompanying 
febrile relaxation of the heart-chambers. (See Mitral Insuffi- 
ciency.) Confusion with pericardial rub (q. v.) is possible. 

Prognosis. — (a) As to life, the outlook is generally good, unless (i) 
emboli lodge in important structures, such as the basilar or coronary 
arteries, or (ii) the process becomes malignant. (b) As to complete 
recovery, (i) valvular lesions are usual and, (ii) fresh recurrent endo- 
carditis is very common. 

Treatment. — The treatment of the two forms of endocarditis is 
considered together, (a) Prophylaxis resolves itself into the treat- 
ment of the causal acute infection, such as rheumatism or sepsis. 
Preventive treatment, such as the administration of salicylates and 
alkalies in rheumatism, is uncertain except that they shorten the rheu- 
matic attack, (b) Rest spares the heart and probably lessens the 
percentage of cases involved. Complete rest, psychical and physical 
(cardiac), is the prime essential, and cardiac stimulants are to be 
avoided, at least in the early stages. Rest in bed must be enforced for 
weeks after temperature and signs of heart weakness have wholly 
disappeared. Should relative recovery occur, the general care of 
the heart's strength must be insisted upon as in chronic valvular 
disease, and, with intercurrent affections or with the appearance of 
temperature, the patient must be confined to bed. (c) The sepsis is 
treated by alcohol (see Pneumonia) ; quinine, gr. x to xv, once or 
twice daily, with three ounces of red wine every hour or two, is recom- 
mended by Fraentzel; bichloride of mercury and other antiseptics are 
futile; for pure or dominating streptococcic infections Marmoreck's 
antistreptococcus serum is indicated in doses larger than those usually 
prescribed, and should be frequently repeated, (d) The irritable heart 
may be quieted and slowed by the use of the ice-bag. Sinapisms 
sometimes act favorably but blisters are to be avoided. Cardiac 
stimulants should be employed with caution, and only coffee, am- 
monia, or brandy, should be given. Digitalis is usually to be avoided, 
but it is indicated when very tumultuous heart action threatens to 
induce embolism. 

(e) Symptomatic Treatment. — For nervous symptoms, sodium brom- 
ide is indicated. Sulphonal and trional are to be avoided when the 
heart weakens. For the fever, hydrotherapy, aside from simple 
sponging, is inadvisable, for the joints and muscles are very tender, and 
movement, on account of the possibility of embolism, is dangerous. 
Diarrhoea of septic origin should not be checked at once, because it 
is nature's effort at derivation and elimination. Fluid diet should be 
given because of the fever. Potassium iodide is usually administered 
as a resolvent after the acute stage has passed. 



400 DISEASES OF THE CIRCULATION 



II. Chronic Endocarditis. Chronic Valvular Disease. 

Etiology. — Valvular heart disease constitutes 2 to 9 per cent, of 
all diseases. It often develops from (a) acute verrucose endocarditis, 
and therefore has the same etiology. Some cases develop without 
symptoms and are apparently primary or possibly hereditary; they 
are seen mostly in young or adolescent subjects and in women. (6) 
Atheroma is also an important cause; it is promoted by overexertion 
(as in the working classes), by advanced years, or by chronic nephritis, 
gout, diabetes, syphilis, alcoholism, and lead poisoning. It is a more 
common cause in males. Though chronic valvular disease may develop 
from other causes than chronic endocarditis, both topics can well be 
considered together. Valvular lesions less often result from (c) rup- 
ture of the valves; this occurs most often in the aortic valves during 
supreme physical efforts, and is promoted of course by previous val- 
vular lesions, although it is sometimes observed in perfectly normal 
valves. Healing is most rare, (d) Relative valvular insufficiency is 
a condition in which the normal valves are unable to close the orifices 
to which they belong because the heart is dilated. It is most com- 
monly tricuspid and mitral, although it also occurs in the aortic and 
pulmonary valves. Relative stenosis is not clearly established, (e) 
Other rarer causes are aortic aneurysms, neoplasms, valvular aneu- 
rysms, and cardiac thrombi or trauma. 

Pathology. — Small grayish-red swellings are sometimes seen in the 
early stages; they somewhat resemble atheroma plaques. Foci of 
endocardial thickening and retraction (endocarditis retrahens) are seen, 
in which calcification and even ossification of the valves may be pres- 
ent. The valves become less translucent, are not infrequently rigid, 
unable to unfold, adherent to each other or distorted by their own 
thickening and retraction or that of the chordae or papillary muscles. 
Mural changes are unimportant, except when associated with myo- 
carditis. Acute exacerbations may occur and the ordinary vegetations 
appear. Embolism occurs in about 30 per cent, of the cases. The 
myocardial changes are hypertrophy, dilatation, and myocarditis. The 
valves most often involved are the mitral (78 per cent.), especially in 
adolescence, then the aortic (20 per cent.), which are especially subject 
to change in arteriosclerotics, and finally the tricuspid (1 per cent.), 
and the pulmonary valves. Combined valvular lesions occur in 33 
per cent, of cases. The process often extends by continuity of surface 
from the mitral to the aortic valves. In fcetal cases (v. Congeni- 
tal Valvular Disease) the valves of the right heart are more 
frequently involved. When one valve is but moderately involved, 
the others of the same valvular orifice may compensate by stretch- 
ing in order to cover the defect, especially in aortic disease. 

Valvular insufficiency is usually caused by (a) thickening and retrac- 
tion or even calcification of the valves and also of the chordae ten- 
dineae and of the papillary muscles; (b) massive vegetations; (c) 



AORTIC INSUFFICIENCY. (CORRIGAN'S DISEASE) 401 

growing together of the valves, or of the valves with the wall of the 
heart or aorta; or adhesions between the papillary muscles and ten- 
dons; (d) valvular aneurysm, perforation, rupture, or tearing of the 
tendons or muscles. Valvular stenosis (stenosis of the orifice) results 
from (a) adhesions between the valves, (b) retraction, calcification, 
fibrosis of valves or ring of insertion, (c) vegetations. Combined val- 
vular insufficiency and stenosis in one valvular mechanism, especially 
the mitral, is most common. 

Symptoms. — The symptoms of valvular disease are (a) the cardiac 
findings peculiar to each lesion, which will be first considered, and (b) 
the general symptoms more or less common to all forms of cardiac 
insufficiency, the description of which will follow the individual lesions. 



III. Aortic Insufficiency. (Corrigan's Disease.) 

Etiology. — 1. Endocarditic Form. — The sinuses of the valves may 
fuse, vegetations are present, or the valves grow together at their 
margins and shrink; this is more frequent than valvular perforation 
or ulceration, which is rapidly fatal. If calcification develops, there 
may be coincident stenosis. This form usually follows a previous 
mitral lesion. The endocarditic may be combined with the atherom- 
atous form. 

2. Atheromatous Form. — Atheroma may be slight in the aorta, and 
located mostly on the valves. It is a slow, degenerative process (see 
Arteriosclerosis) with marginal valvular retraction; it is caused 
by excessive use of alcohol, by continued hard work or athletics, and 
by syphilis, which may dilate the aortic ring (syphilitic aortitis), 
even without directly involving the valves. It is often therefore seen 
in middle-aged men. A relatively slight anatomical lesion may 
produce disproportionate symptoms. The atheromatous process may 
overlie or actually invade the coronary orifices. This is obviously 
dangerous. The valves may become adherent to the aorta. Their 
edges are rounded, and are not the seat of endocarditic masses. 
Coincident stenosis is infrequent. Relative insufficiency and con- 
genital defects are less frequent. 

3. Relative Insufficiency. — This form occurs mostly in cases of aor- 
titis, aneurysm, and arteriosclerotic dilatation of the root of the aorta, 
which is a more or less physiological process, as the aorta usually 
relaxes one centimeter in circumference after the fortieth year. It 
may also occur in cases of dilatation of the left ventricle, resulting from 
idiopathic hypertrophy, from myocarditis, or from renal disease. 

4. Congenital Defects. — These are rare; absence of a valve may be 
in part compensated for by the others, though anatomical anomalies 
predispose to sclerosing endocarditis. Valvular fenestration is unim- 
portant clinically and pathologically. 

5. Trauma. — This is a most uncommon cause, only 25 cases being 
recorded (Trevisanello, 1904). 

26 



402 DISEASES OF THE CIRCULATION 

Mechanism. — From aortic valvular incompetence, a diastolic regur- 
gitation of blood into the left ventricle takes place from gravity and 
contraction of the aorta. Blood currents and vibrations are caused by 
the blood flowing (normally from the left auricle and pathologically 
from the aorta) into the left ventricle, thereby producing the diastolic 
murmur. The left ventricle becomes hypertrophied, because it must 
propel the normal plus the regurgitated blood, and becomes dilated to 
accommodate its added volume. The size of the left heart becomes 
enormously increased, and may even weigh 50 ounces, whence the 
name "ox-heart," — cor bovinum. The hypertrophied left ventricle 
suddenly forces an unusually large amount of blood into the arteries, 
and thus causes the many arterial phenomena. 

Physical Signs. — 1. Inspection. — (a) Precordial prominence is ob- 
served chiefly in plastic chests, and, therefore, is most common in 
women and children. Mensuration may confirm the prominence, 
although the right chest normally measures nearly an inch more than 
the left, (b) The heart shock is powerful and diffuse, (c) The apex 
beat is dislocated downward (6th, 7th, 8th interspace) and outward, 
beyond the nipple or anterior axillary line. The apex lies low in arte- 
riosclerotics, from relaxation of the aorta. It is heaving, pulsating, 
and superficial. The lung is pushed back and some slight rotatory 
systolic retraction of the chest wall is seen. These findings are re- 
ferred to the dilated and hypertrophied left heart, (d) Pulsation in 
the first and second right intercostal spaces is usually dynamic, be- 
cause the extra volume of blood thrown with extra force into the 
aorta causes dilatation of the aortic arch, (e) The peripheral vessels 
pulsate with unusual violence, and the carotids hop; pulsation in the 
jugular fossa, or in the abdominal aorta, may simulate aneurysm, and 
the temporals and radials often attract attention before the pa- 
tient undresses for examination; these are all caused by ven- 
tricular hypertrophy and the extra volume of blood thrown into 
the vessels. Pulsation may also be seen in the retina, either spon- 
taneously or by pressure on the eyeball, as occurs also in Basedow's 
disease. The liver may pulsate, though this is rare because a 
strong heart action with stasis is necessary. The liver also pul- 
sates in cases of tricuspid incompetency, but this throb is due to 
venous filling of the organ during the systole. Pulsation also oc- 
curs in the spleen, palate, and penis. (/) The capillary (Quincke's) 
pulse, occurs in over 80 per cent, of the cases, but is not pathog- 
nomonic, for it is also seen in health and in fevers or ansemias. It is 
a symptom of overfilling of the arteries and capillary dilatation, and 
is best observed when the hypertrophy exceeds the dilatation; it dis- 
appears when the heart weakens. It is elicited by exerting slight pres- 
sure on the tips of the finger nails, on the lips by a glass slide, or by 
rubbing the forehead until it is red; there is a systolic reddening and 
a diastolic paling in these parts. It is sometimes found in the retina, 
in the palate, or in cases of complicating erysipelas, (g) The passing 
over of the blood from the arteries into the veins may produce the 



AORTIC INSUFFICIENCY (CORRIGAN'S DISEASE) 403 



centripetal venous pulse. This is seen most advantageously in the fore- 
arm, and is caused by (i) relaxation of the vessels, as in fevers, some 
nervous lesions, and chlorosis ; (ii) by delicate skin; and (hi) full heart 
action, (h) The arteries are actually lengthened, (i) Patients often as- 
sume the dorsal decubitus, for gravity increases the leakage; subjects 
with mitral insufficiency usually sit. 

2. Palpation. — (a) The hand corroborates the results of inspection, 
— as the heaving, throbbing apex. (b) A diastolic thrill over the base is 
infrequent, but when present is usually proportionate to the degree of 
leakage, (c) In the jugulum, especially in arteriosclerotics, the widened 
aorta can be felt, (d) The pulse findings may seem paradoxical, but it 
must be noted that (i) the arteries are filled violently (the pulsus durus), 
though (ii) the tone of the vessel wall is less than normal. 

Fig. 22. 




Sphygmogram of case of uncomplicated aortic leakage. 

The radial artery is suddenly filled ("pistol pulse"), the pulsus 
celer; this is due to hypertrophy of the left ventricle. The condition 
of the heart muscle, and therefore of the pulse, depends largely on the 
type or etiology of the case; hypertrophy is usual, and marked in the 
endocarditic form, though in the atheromatous type coronary athe- 
roma and fibrous myocarditis lessen the myocardial activity, render 
the pulse atypical, and make the prognosis less favorable. The sphyg- 
mographic tracing shows the high up-stroke with an acute apex (the 
pulsus alius). The dicrotic wave is ill-marked, and the pulse rapidly 
recedes (the "collapsing pulse"), due to the inability of the aortic 
valves to hold the receding blood. The falling away of the pulse is 
sometimes increased by lifting the arm. The pulse is not absolutely 
characteristic, because it also occurs in fevers or ansemias, but it is 
strongly suggestive. The typical findings are altered, (a) when athe- 
roma of the aorta or vessels occurs; (b) when other valvular lesions de- 
velop, as aortic stenosis or mitral regurgitation; (c) when the heart is 
weak or degenerated. When the pulse findings precede the murmur it 
is claimed that the lesion is due to disease of the aorta. Thrills may 
be felt over various peripheral vessels. The peripheral pulse is delayed 
in about half of the cases, because the regurgitation continues into the 
first part of the systole. 

3. Percussion. — (a) The heart area is oval, and is increased down- 
ward and to the left, as could well be anticipated from the mechanism. 



404 DISEASES OF THE CIRCULATION 

Dulness reaches the second or third ribs to the left of the sternum (See 
Plate VIII, Fig. C). The heart is somewhat more horizontal than 
normal. The dulness extends slightly beyond the apex and is 
largely due to dilatation of the left ventricle. Because physical laws 
demand its equal dilatation in all directions, it is not surprising that 
the right heart may be somewhat crowded to the right, and the left 
auricle upward, although dulness to the right of the sternum is infre- 
quent. The papillary muscles are found flattened and even thickened 
at autopsy, from the pressure of the regurgitant blood, (b) A small 
area of dulness in the first and second right interspaces denotes mechan- 
ical dilatation of the arch, which results from the cardiac hypertrophy. 
4. Auscultation. — (a) A diastolic murmur is heard over the sternum 
at the level of the second or third rib. It is caused by the retrograde 
blood passing through the incompetent valves into the left ventricle. 
When heard over the so-called "pulmonic area/' it is increased down- 
ward along the sternum, for the regurgitant column follows this direc- 
tion (Plate VIII, Fig. C). It has a blowing, deep, and less often sawing, 
musical or whistling sound (which latter suggests a relative aortic 
leakage). When slight, it may easily escape recognition, but when 
well developed it is very characteristic, sounding like the word "who." 
It sometimes disappears before death when the heart is weak and the 
lesion is great, but generally corresponds to the degree of leakage. It 
rarely reaches the neck or abdomen. Cases of valvular rupture have 
produced a murmur which could be heard at a distance, (b) A slight 
systolic murmur over the valves or aorta is not uncommon, but the too 
frequent diagnosis of aortic stenosis (see Pulse and Thrill under this 
topic) is not justified. It is soft in the atheromatous, and often harsh in 
the endocarditic type. Its various explanations are : Rough aorta or 
valves, physiological stenosis (the rigid valves lying between a wide aorta 
and a dilated ventricle); vibration of the aorta; or leakage continuing 
into the beginning of the systole, (c) Weakness or absence of the second 
aortic tone is explained by imperfect closure of the valves. Because the 
second tone is normally heard over the carotid artery it should be 
listened for there, because it is removed from the murmur and the 
second pulmonic tone. If it is present, the usual conclusion is that one 
or more valves are closing, though possibly imperfectly. By lifting 
the stethoscope a little from the skin over the aortic region, the second 
sound, which was previously obscured by the bruit, may be heard. 
(d) The first mitral tone is often weak, or lost, because the papillary 
muscles are flattened and indurated by the regurgitant column. If 
the change is pronounced, a mitral systolic murmur may be heard in 
place of the first tone, (e) An apical presystolic (Flint's) murmur is 
heard in 50 per cent, of the cases, and is due to aortic leakage continued 
in the systole, or to pressure on the mitral valves, which hinders the 
flow of blood from the left auricle into the left ventricle. Thayer found 
it in 60 per cent, of 74 cases, and in less than one-quarter of these was 
there a mitral stenosis. (/) Arterial tones and murmurs may result from 
vibration of the vessel wall ; these tones may become murmurs, when 



AORTIC STENOSIS 405 

there is great difference in tension. The systolic vessel tone is in- 
creased from the larger volume of blood and increased ventricular 
action, and is most plain when the vessels are not sclerotic. It is also 
found in anaemia. Over the femoral artery, a systolic tone is heard 
which is convertible into a murmur on pressure. Traube's double 
femoral sounds consist of two spontaneous (i. e., produced without 
pressure) tones, which are variously explained, probably most satis- 
factorily by sudden change in tension. They are heard best when the 
heart is strong and the vessels soft. They occur in other conditions 
and in valvular lesions, and may be confused with the double venous 
(Friedreich's) tones, which are heard over the vein in tricuspid leakage. 
Duroziez's double murmur is analogous, but consists of two murmurs, 
which may be elicited by slight pressure and are due to the progress 
and recession of blood in the artery. It also occurs in other conditions. 

Diagnosis. — Physical examination by inspection, palpation, per- 
cussion, and auscultation, in the order named, prevents many errors in 
the interpretation of murmurs. The cardinal findings are: (a) Dilata- 
tion and hypertrophy of the left ventricle; (b) the pulsus celer and 
altus; (c) the arterial phenomena; and (d) the diastolic murmur. 

Relative aortic regurgitation (see Etiology) is difficult to differentiate 
from the valvular; the murmur is not the typical protracted diastolic 
bruit, but rather a short presystolic (or postdiastolic) murmur (Rosen- 
bach) which produces a short "huff" after the second aortic tone. 
This character is said to be almost pathognomonic. The pulse in rela- 
tive regurgitation is frequently small, tardy, and tense, but not quick. 
Hypertrophy of the left ventricle is not very great. The murmur 
varies from time to time; it is sometimes short, then longer, sometimes 
blowing, and again coarse, or it may be difficult to fix as to systole or 
diastole. 

Diastolic murmurs are rarely aneemic (cardiopulmonary or func- 
tional). Clear instances exist, however, of bruits in the cava and other 
veins. These murmurs are uneven, and are stronger in the beginning 
of the diastole. Aortic aneurysm (q. v.) may cause confusion. In 
mitral lesions, the capillaries are poorly filled and the skin is cyanotic; 
in aortic regurgitation the arterioles are overfilled and the skin is red. 
In mitral disease, congestion of the lung, brown induration, and dila- 
tation of the right heart obtain; these are absent in aortic leakage; a 
hemorrhagic nephritis takes the place of the analogous brown indura- 
tion of the lungs of mitral lesions. 

Relative healing by vicarious stretching of sound valves, by growing 
stenosis, and by calcification, is possible but infrequent. 



IV. Aortic Stenosis. 

Aortic stenosis is the most infrequent of left-heart lesions. It may 
occur congenitally, in which case the conus arteriosus is often con- 
stricted (Dittrich's genuine heart stenosis). It occurs, however, 



406 DISEASES OF THE CIRCULATIOX 

largely in the aged. The valves become interadherent or thickened, 
and calcarious masses or retraction at their insertion obstruct the ori- 
fice. Acute endocarditis, with massive vegetations, may produce some 
stenosis. It is usually associated with aortic incompetency, although 
aortic double lesions are far less common than mitral. Stenosis of the 
aortic orifice is a better term than aortic stenosis. 

Mechanism. — The rigid valves make the orifice narrow, and at the 
obstruction a systolic murmur originates. The resistance to the 
onward flow of blood from the left ventricle, leads to its hyper- 
trophy. The pulse becomes small and slow because of obstruction. 

Physical Signs. — 1. Inspection. — Some precordial prominence may 
be seen in yielding chests. The apex beat is sometimes strong, and at 
times somewhat dislocated to the left, but often no apex is seen, either 
on account of coincident emphysema or because the heart's recoil is 
lessened or absent. The apex sometimes retracts during the systole 
from lack of tension in the aorta and from lessened systolic dislocation 
of the heart. 

2. Palpation. — (a) A most pronounced systolic thrill is often felt 
over the second right interspace, and sometimes is propagated over the 
heart and into the cervical vessels, (b) The pulse is infrequent (pulsus 

Fig. 23. 



Pulse tracing in stenosis of the aortic orifice. 

varus), because the systole is prolonged and the coronary arteries are 
not well filled; it is small (p. parvus), from obstruction to its flow; it 
is tense (p. durus), from hypertrophy of the left ventricle, and from 
arteriosclerosis; and it is exceedingly slow (p. tardus) with tardy up- 
and-down stroke and some retardation, as compared with the apex 
beat. A strong apex beat and a weak radial pulse suggest aortic 
stenosis. 

3. Percussion. — This may be wholly negative. Concentric hyper- 
trophy (i. e., hypertrophy, with the left heart chamber smaller than 
normal), is very frequent. Concentric and simple hypertrophy, which 
are the more common, as the stenosis is purer, naturally give no change 
on percussion. Dilatation is sometimes present, giving slight dulness 
to the left, especially with aortic regurgitation, renal contraction, or 
atheroma. In rare instances, hypertrophy and dilatation are both 
absent. 

4. Auscultation. — Auscultation gives (a) a systolic murmur over 
the aortic area, which is sometimes soft but more often long, sawing, 
whistling, or musical, and is transmitted with the blood current into 
the aorta, the descending aorta in the back, and its vessels (Plate VIII, 
Fig. A). It is frequently heard over the entire heart, and at times is 
heard at some distance from the chest. It is not proportionate to the 
intensity of the lesion, and disappears with broken compensation. 
(b) The second aortic sound is weak, from poor filling of the aorta and 
weak closure of the altered valves, or it is absent, when combined with 



MITRAL INSUFFICIENCY 407 

aortic regurgitation; (c) when the second aortic sound is absent, the 
second mitral tone, or indeed all the heart tones, are weak or absent, 
(d) A systolic tone is heard over the aorta. 

Diagnosis. — The lesion may be a favorable sign, because it is some- 
times a healing of an aortic regurgitation. Aortic stenosis is a fre- 
quent surprise at autopsy, having run a latent course. The cardinal 
symptoms are (a) systolic murmur with propagation into the large 
vessels, which is frequently heard over the entire heart; (b) a 
systolic fremissement over the aortic area; (c) the small, tardy, 
slow pulse, in contrast to the strong apex beat. A diagnosis should 
be reserved unless these signs are present. As the lesion is uncom- 
mon, its frequent diagnosis implies confusion with (i) accidental mur- 
murs, which are variable but which may resemble a slight stenotic 
murmur, (ii) Acute endocarditic vegetations; these usually give a soft 
murmur which becomes harsher if actual stenosis ensues, (hi) Athe- 
roma of the aorta, or acute aortitis, where the murmur is more localized 
over the aorta, the second aortic tone is ringing or metallic, and the pulse 
is generally proportionate to the apex beat. Atheroma is the most 
frequent cause of diagnostic error; it is very common, while experi- 
enced clinicians see few cases of pure aortic stenosis, (iv) Aneurysm 
(q. v.), which is often distinguishable by its pressure symptoms. 



V. Mitral Insufficiency. 

Mitral insufficiency (incompetency, regurgitation) is the most fre- 
quent valvular lesion. It is (a) valvular, from adhesions between the 
valves or chordee or ventricular wall, from vegetations, from thickening 
with retraction, from valvular aneurysm or perforation, or from shrink- 
age or rupture of the papillary muscles or chordae; or it is (b) 
muscular, from relative insufficiency due to such relaxation of the 
ventricular muscle that the valves will not cover the orifice; it is most 
common in hypertrophy with dilatation, resulting from hard work, 
atheroma, nephritis, syphilis, alcoholism, myocarditis, adherent peri- 
cardium, and exophthalmic goitre; (c) rupture of the mitral cusps is 
very uncommon. Barie collected 35 cases of valvular rupture, of which 
45.7 per cent, were aortic, 45.7 per cent, were mitral, and 8.6 per cent, 
were tricuspid. 

Mechanism. — During the systole, a backward flow occurs through 
the incompetent valves into the left auricle, which, as it also receives 
blood from the lung veins, must first dilate and later hypertrophy, as 
far as its slight musculature can admit. The left ventricle dilates be- 
cause it receives in the diastole more blood than normal (i. e., the usual 
inflow plus the already regurgitated blood), and it hypertrophies be- 
cause its work is increased. In aortic lesions, the first and greatest 
strain is felt in the left ventricle, but mitral lesions, by congesting the 
lungs, throw the most work on the right heart. The stasis in the left 
auricle is transmitted to the pulmonary veins, capillaries, ami arteries, 



408 DISEASES OF THE CIRCULATION 

thus leading to increased engorgement and blood pressure in the pul- 
monary circuit, because (a) of this backward pressure, and (b) of the 
onward pressure from the right ventricle, which hypertrophies. The 
lungs are enlarged and engorged, their vessels dilate and may become 
atheromatous, possibly causing infarcts in the lung, and connective 
tissue development (brown induration). When the final inevitable weak- 
ening of the right ventricle occurs from dilatation, i.e., broken compen- 
sation, the right auricle is engorged and relative tricuspid leakage (v. i.) 
follows from dilatation. The venous system is overloaded, and this 
results in stasis and cyanotic induration of the viscera, liver, and kid- 
neys, and often in oedema. 

Physical Signs. — 1. Inspection. — (a) The apex may be normally 
located or displaced to the left — even into the axilla when there is much 
dilatation. The heart may then lie lower than normal. The normal 
force of the apex beat in mitral insufficiency is evidence of hypertrophy, 
(b) Systolic pulsation in the second left interspace indicates a wide 
pulmonary artery from increased tension or stasis, and (c) a diastolic 
shock there is due to closure of its valves; (d) precordial prominence 
occurs in yielding chests from marked cardiac dilatation; (e) pulsa- 
tion, either epigastric or to the right of the sternum, results from dilata- 
tion and hypertrophy of the right ventricle. (/) The veins are enlarged 
and pulsate during the diastole from stasis, and sometimes during the 
systole from tricuspid incompetency (q.v.) or patency of the foramen 
ovale. 

2. Palpation. — (a) The apex is dislocated to the left; (b) the pulmonary 
pulsation is felt; (c) the diastolic shock of the forcibly closing pul- 
monary valves is very often palpable by placing one finger over the 
valves and another over the apex whereon the two shocks alternate; 
(d) pulsation is felt to the right; (e) a systolic apical thrill is often 
palpable after physical or psychical excitement, or when the patient lies 
on his left side, but it is not pathognomonic. (/) In pure cases the pulse 
is of about normal tension in compensation, or becomes lessened with 
rupture of compensation. Irregularity is not very common and the 
sphygmographic tracing is not characteristic. 

3. Percussion. — This shows (a) dilatation of the right ventricle in 
compensated cases, which is commonly followed by hypertrophy. 
Dilatation shows dulness and palpatory resistance to the right of the 
sternum (See Plate VIII, Fig. B). Hypertrophy without dilatation is 
usually found in the early and well compensated lesion. It should be 
remembered that the right heart bears the stress of this lesion. (6) 
The left ventricle usually but not always dilates to respond to the 
increased amount of blood, and hypertrophies because of increased 
work or because of the raising of arterial pressure by carbon dioxide. 

4. Auscultation. — (a) The systolic murmur is due to abnormal 
eddies in the left auricle or to the vibrations caused by them in the 
mitral valves; it most often gives a blowing sound, is best heard over 
the apex, which is less covered by the lung, but at times is best recog- 
nized over the pulmonary area or auricle, where it really originates and 



MITRAL INSUFFICIENCY 409 

where it is heard especially in early lesions. It is transmitted chiefly 
towards the left interscapular region, and to the left; and more rarely to 
the aorta, carotids, and abdomen (See Plate VIII, Fig. B) ; it is at times 
heard intermittently, in certain postures only, and it may disappear 
with weakening of the heart. In very rare cases it is entirely absent 
(latent). (6) The first mitral tone is usually absent because the valves 
cannot vibrate; if present it is referable to conduction from the tri- 
cuspid valve or to contraction of the ventricle. When obscured by the 
murmur, it may sometimes be heard by lifting the stethoscope a little 
from the chest wall. In cases of extreme leakage, the murmur replaces 
all tones, (c) The second pulmonic sound is accentuated, " hammer- 
like, " and is a measure and result of the right ventricular hypertrophy 
(Skoda). It sometimes reaches the vessels of the neck. When the 
tricuspid valves become relatively insufficient, it usually weakens; 
accentuation is absent in those rare cases where the right ventricle does 
not hypertrophy. The second tone at the base is sometimes split, (d) 
A systolic murmur over the pulmonary area is usually propagated from 
the apex or is due to vibrations in the distended pulmonary artery. 

Diagnosis. — The cardinal features are (a) the systolic murmur, (6) 
the accentuated second pulmonic tone, and (c) the right-heart changes. 

Excepting the etiological diagnosis, there are no positive criteria by 
which we can differentiate a muscular (relative) from a valvular in- 
sufficiency, though in the former the murmur is more variable, lessens 
with digitalis, and is not associated with a diastolic murmur which is 
common in valvular incompetency. Pure insufficiency is very excep- 
tional, being usually combined with some mitral stenosis into which 
insufficiency may eventually pass. (A cure is thus sometimes effected.) 

From the functional, accidental, haemic, or cardiopulmonary mur- 
mur, the diagnosis is usually easy. This murmur is inconstant, is often 
basal, often depends on posture and coughing efforts, is circumscribed, 
sometimes disappears on pressure, is not typically transmitted, follows 
fever, anaemia, and emphysema, is often associated with the venous 
hum in the neck, but is never associated with typical mitral changes in 
the heart tones and right ventricle. The intensity, timbre, or fremisse- 
ment, of the murmur must not alone be depended upon. So-called 
"functional" murmurs are usually systolic. 

In chlorosis, we may obtain a hsemic murmur, apparently large heart 
(because the lungs are poorly expanded), and a displaced apex, since the 
diaphragm stands high in chlorosis ; deep breathing rapidly decreases 
the heart's dulness. 

Pericardial friction (q. v.) may simulate any endocardial murmur 
(Skoda), though most clinicians find little difficulty in distinguishing 
them. 

Fraentzel's general rules are excellent and aid in accuracy: (1) Never 
make a diagnosis just before death. (2) Remember the great infre- 
quency of right-heart lesions. (3) Avoid complicated diagnoses. (4) 
Murmurs are subordinate in value to physical findings by inspection, 
palpation, and percussion. 



410 DISEASES OF THE CIRCULATION 



VI. Mitral Stenosis. 

Pure stenosis of the mitral orifice is rare and is an almost constant 
anatomical associate of mitral leakage. The mitral valves are so grown 
together or the ring so constricted as to well justify the name used by 
Corrigan, "the button-hole contraction. " The orifice in extreme cases 
is funnel-shaped. It is more frequent in the young and in women (76 
per cent, of the cases). 

Mechanism. — The stenosis obstructs the diastolic passage of the 
blood into the left ventricle from the left auricle, which consequently 
dilates and later hypertrophies. The enlarged auricle may compress 
the adjacent bronchus or recurrent laryngeal nerve. The stasis is pro- 
pagated backward through the lungs to the right ventricle, whose 
dilatation and hypertrophy cause the large right heart and the in-r 
creased pressure in the lesser circulation. The effects on the right 
heart and lungs are more severe than in mitral insufficiency. The right 
auricle also dilates when the later venous stasis follows. Thrombi in 
either auricle may dislodge and produce pulmonary or arterial infarc- 
tion. The arterial system is naturally filled but poorly. 

Physical Signs. — 1. Inspection. — This reveals (a) precordial dis- 
tention, (b) epigastric pulsation, and (c) a diffuse cardiac shock; (d) the 
apex beat may in comparison be small, and (e) two impulses or shocks 
may be seen in the second left interspace; one is systolic, from systolic 
filling of the pulmonary artery, and the other is diastolic, from pul- 
monary valve closure under high tension. All these findings depend 
on changes in the right heart. 

2. Palpation. — Palpation confirms the above, especially (a) the apex 
beat, which is often weak in comparison with the diffuse heart impulse, 
(6) the snap of the second pulmonic sound, (c) the pulsating right heart, 
and also (d) a presystolic (more rarely diastolic) thrill (fremissement 
cataire) which is usually limited to the apex, ends with the snappy first 
apex-tone, and is felt sometimes only in the left lateral posture, after 
exertion or when the arms are raised. Its mechanism is identical with 
that of the murmur (q. v.). (e) The pulse is often irregular even with 
good compensation, especially in cases of pure stenosis, and is usually 
small and of low tension, because the aorta is poorly filled. It some- 
times seems hard, and at times its weakness contrasts conspicuously 
with the active heart impulse. The pulse is not pathognomonic 
but merely suggestive; the sphygmograph confirms the palpatory 
findings. 

3. Percussion. — (a) The right ventricle in the earlier stages may be 
only hypertrophied, which does not show on percussion. Dilatation 
without hypertrophy exists in few cases fortunately, for the prognosis 
is then poor. Most commonly hypertrophy and dilatation coexist, the 
latter giving increased dulness to the right, as is the case in mitral in- 
sufficiency, (b) The left ventricle in many cases of dominant stenosis 
shows concentric atrophy, so that at autopsy it looks like a mere appen- 



MITRAL STENOSIS 411 

dage to the huge right heart. It is sometimes both hypertrophied and 
dilated, for which the following reasons have been assigned : Marked 
concomitant mitral leakage; stasis with increase in the blood of car- 
bon dioxide, which raises the blood pressure; coincident adherent 
pericardium, nephritis, atheroma, or aortic disease, all of which lead 
to changes in the left ventricle, (c) The auricles are distended, much 
of the dulness under or beyond the sternum being due to the dilated 
right auricle and that above and to the left, to the left ventricle. 
(The right conus arteriosus and the pulmonary trunk are found 
widened at autopsy.) Increased dulness, due apparently to dilatation 
of the various chambers, is often caused merely by their dislocation by 
the wide right ventricle. 

4. Auscultation. — (a) An apical presystolic murmur is important. 
It occurs at the end of the diastole just before the ventricular systole, 
i. e., during the auricular systole which forces the blood through the 
narrowed ring or rigid adherent valves. Corresponding with the energy 
of that chamber, it is loudest at the incipiency and ending of the 
murmur. It so closely precedes the ventricular systole that it is often 
called systolic by physicians and is almost invariably mistaken by 
students. It is rarely a blowing sound, but usually snoring, rolling, 
sounding like R-R-R-P, after which comes the loud first tone. It is 
poorly propagated as a rule, corresponding to the localized thrill 
(v. s.), but may in exceptional cases, be heard in the axilla or back. 
It is most variable, often being absent even with great stenosis, and 
appearing again only after exertion ; it is absent when the heart weakens 
and before death, whence the importance of Rule 4 of Fraentzel (see 
Diagnosis of Mitral Insufficiency). It is rarely diastolic, (b) Marked 
accentuation of the second pulmonic sound is the proof and measure of 
hypertrophy of the right ventricle from pulmonary congestion. Its 
absence is a poor prognostic. It usually weakens when relative tri- 
cuspid leakage intervenes and thereby lessens the tension in the lungs. 
The accentuation rarely reaches the cervical vessels, (c) Splitting or 
reduplication of the second pulmonic sound is due to difference in 
tension in the two arterial trunks, the aortic valves closing first and 
more weakly. The doubling is best heard at the base and is often 
propagated into the neck or axilla, (d) The usually loud first mitral 
tone is explained in various ways; viz., by difference in tension of the 
valves during the systole and diastole or by a vigorous contraction of 
the left ventricle upon little blood. It is sometimes heard at a distance 
of several feet.; (e) The second mitral tone is weak because of poor 
filling of the aorta or because the right heart comes forward more than 
usual. This tone may be split at the apex (the "postman's knock"), 
and may be present early in this lesion; the cause of the splitting is 
the subject of variant discussion. 

Diagnosis. — The cardinal signs are (a) the presystolic thrill and 
bruit; (6) the involvement of the right heart; (c) the accentuated 
second pulmonic sound; (d) the small pulse, which is less important 
and (e) loud first apical tone. 



412 



DISEASES OF THE CIRCULATION 



The thrill and bruit are also found in other conditions, as in aortic 
insufficiency (Flint's murmur), in which the vascular phenomena and 
the involvement of the left heart are sufficiently distinctive, though one 
out of every three cases of aortic leakage is complicated by mitral 
stenosis. The bruit has also been heard in lesions leading to dilatation 
of the left ventricle, such as adherent pericardium, whence the rule that 
the diagnosis of mitral stenosis must be conservative when there is a 
clear history of pericarditis or where the left ventricle is dilated. 

When the thrill and murmur are absent, the diagnosis can very often 
be made by the other cardinal symptoms. 

It has been held that (a) an absence of the murmur indicates a slight 
lesion, as also does (b) a presystolic murmur; (c) a diastolic murmur 
indicates a severe stenosis ; and (d) absence of the murmur with irregu- 
larity is indicative of the most serious lesion. 

Differential Table of the Common Chronic Valvular Lesions. 



Aortic 
Insufficiency. 



Aortic 
Stenosis. 



Mitral 
Insufficiency. 



Mitral 
Stenosis. 



Etiology. 



Pulse. 



Left Ventricle. 



Right Ventricle. 



Murmur. 



First Mitral 
Tone. 



Second Aortic 
Tone. 



Second Pulmon- 
ary Tone. 



Peripheral 

Vessels. 



Arteriosclerosis 
chiefly. 

Pulsus celer. 
Water-hammer , 
collapsing. 

Hypertrophied 
and dilated 
greatly; heaving 
apex. 

No change. 



Diastolic; blowing 
over sternum near 
second rib; prop- 
agated toward 
apex. 



Usually weak. 

Weak or absent. 
Not accentuated. 



Violent pulsation; 
capillary pulse; 
arterial tones; skin 
red. 



Often arterioscler- 
otic. 

Pulse, small, slow, 
tense. _ _ ._ 
i 11 *! M 

Hypertrophy, 
usually concentric. 



No change. 



Harsh systolic 
murmur over aor- 
tic area with sys- 
tolic thrill; prop- 
agated into neck. 



Strong usually. 



Weak only. 



Not accentuated. 



Absent. 



Endocarditis 
chiefly. 

No characteristic 
alteration — often 
normal. 

Some hypertrophy 
and dilatation. 



Hypertrophy and 
dilatation marked. 

Systolic at apex, 
blowing, transmit- 
ted into axilla and 
behind scapula. 



Usually present, 
perhaps covered 
by murmur. 



Somewhat weak. 



Loudly accent- 
uated, and often 
palpable. 

Absent. 

Skin cyanotic. 



Ditto. 



Small and often 
irregular. 



No essential nor 
regular change; 
may be small. 



Both marked, also 
in auricles. 

Presystolic (often- 
er than diastolic), 
apical, accom- 
panied by presys- 
tolic thrill, fairly 
localized. 

Loud and sharp, 
clearly palpable 
and following mur- 
mur. 

Somewhat weak. 



Ditto; often split, 
reduplicated. 



Absent. 

Skin cyanotic 



In conjunction with this table, Plate VIII should be consulted. 



VII. Pulmonary Insufficiency. 



Pulmonary insufficiency, of which Barie has collected 58 cases, is 
most uncommon and is often combined with pulmonary stenosis or 
other rare right-heart anomalies. It is (a) congenital, resulting from 



PULMONARY STENOSIS 413 

foetal endocarditis or from supernumerary, or rudimentary valves; 
(b) acquired from rheumatism, from sepsis, which destroys the valves 
by ulceration or from atheroma; or it is very rarely (c) relative from 
extreme intrapulmonary blood pressure, or from embolism of the 
pulmonary trunk or its branches. 

Mechanism. — The mechanism is analogous to that of aortic insuffi- 
ciency except that the right heart suffers instead of the left and the 
arterial phenomena are manifest in the area of the pulmonary artery. 

Physical Signs. — 1. Inspection. — The right heart is dilated and 
hypertrophied, and pulsates under and to the right of the sternum. 
It may slightly dislocate the apex to the right. A systolic dynamic 
pulsation may be seen over the pulmonary trunk, which is also 
dilated. 

2. Palpation. — This determines the diffuse right-heart impulse in 
20 per cent, of cases, and a diastolic thrill over the pulmonic area, 
though the apex beat is normal or weak and the radial pulse is practically 
normal. 

3. Percussion. — Percussion confirms the schematic expectation that 
the right ventricle should be dilated because of the backward fall of the 
regurgitant column of blood and should be hypertrophied to maintain 
the onward flow under this burden. The left ventricle is normal or 
sometimes atrophic. (See Plate VIII, Fig. E.) 

4. Auscultation. — A diastolic murmur is heard, which is propagated 
down the sternum over the right ventricle. This bruit may be confused 
with that of aortic leakage, aneurysm, a dislocated aorta, functional 
venous murmurs, congenital anomalies of the vessels, or patent foramen 
ovale. The second pulmonic and the second tricuspid tones are weak 
or absent and are replaced by the murmur. The bruit is but rarely 
heard in the neck and the normal second arterial tone is heard over the 
carotids (see Aortic Insufficiency). A systolic murmur (heard in 25 
per cent, of cases) over the pulmonary trunk is due to vibrations in 
its walls or to coincident stenosis of the pulmonary ring. A double tone 
has been heard over the lung, as well as variation in the respiration 
during the systole, — a capillary pulse in the pulmonary vessels. 



VIII. Pulmonary Stenosis. 

The etiology will be considered under diagnosis and under congen- 
ital heart lesions. 

Mechanism and Physical Signs.— 1. Inspection.— Inspection shows 
precordial bulging over the right heart; it also discloses a diffuse heart 
shock from hypertrophy and dilatation of the right heart. The apex 
beat is often weak or absent. 

2. Palpation. — Palpation confirms the above and reveals a systolic 
thrill in the left second interspace. The pulse is negative or weak. 

3. Percussion. — Percussion shows an area of increased dulness over 
the right heart from dilatation. 



414 DISEASES OF THE CIRCULATION 

4. Auscultation. — On auscultation, a loud and usually whistling or 
musical systolic murmur, caused by the stenosis, is often but not al- 
ways heard and the first and second pulmonic tones (and hence also the 
second tricuspid) are weak or absent from poor filling of the pulmonary 
vessel and from valve alteration. (See Plate VIII, Fig. E.) 

Diagnosis. — The most frequent form is (a) the congenital, which is 
due to malformation, myocarditis, or endocarditis, and is usually asso- 
ciated with other kindred lesions (e. g., open ductus Botalli or foramen 
ovale). The obstruction may be below the valves, from myocarditic 
scars narrowing the conus arteriosus, in which case the second pulmonic 
sound is accentuated; or it may be at the valves or in the trunk of the 
artery. Congenital cyanosis and acquired pulmonary tuberculosis are 
common. The murmur may be heard in the neck, (b) The acquired 
valvular form is rare. Atheroma or gummata maybe causal: The thrill 
is also, though far less frequently, felt in accidental murmurs and a 
murmur over this area is most common, because the walls of the artery 
are so thin and compressible as to vibrate easily. These "functional" 
murmurs are so common in this locality as well to justify Fraentzel's 
rule to observe extreme caution in the diagnosis of right-heart lesions in 
the adult. Functional murmurs may occur (i) in health; (ii) after 
fevers; (hi) in anaemia; (iv) as the cardiopulmonary murmur. The 
organic murmur rarely reaches the jugular or cervical vessels. The left 
heart is frequently atrophic. When the acquired stenosis is beyond the 
valve in the pulmonary trunk or lungs, the murmur is heard most ad- 
vantageously beside the right border of the sternum or in the back, and 
the second pulmonic sound is loudly accentuated, from which points a 
diagnosis may occasionally be made. In atresia of the orifice 80 per 
cent, of the subjects die in the first year. 



IX. Tricuspid Insufficiency. 

Etiology. — (a) The congenital form is most rare, isolated tricuspid 
disease occurring in 0.8 per cent, of cases of valvular lesions. The ven- 
osity of the blood in the right heart tends to prevent endocarditis, ex- 
cept in foetal life when the blood is arterial. Myocarditis or ulcerative 
endocarditis may exceptionally occur. (6) Of acquired forms, the rela- 
tive insufficiency is very common, resulting from (i) valvular lesions of 
the left heart, especially mitral stenosis; (ii) obstructive lung lesions, 
such as induration or emphysema; (hi) possibly abdominal lesions 
which reflexly contract the pulmonary vessels, and (iv) in severe anae- 
mias (Leube) ; in anaemic regurgitation cyanosis and dyspnoea are not 
observed. 

Mechanism. — Whatever the cause of the high pressure in the lesser 
circulation, it leads to dilatation and hypertrophy of the right ventricle. 
Extreme dilatation stretches the tricuspid orifice so that the valves are 
incompetent to close it, and relative leakage occurs. The leak back- 
ward into the right auricle produces its dilatation and hypertrophy, 



TRICUSPID INSUFFICIENCY 



415 



a systolic murmur and a systolic pulse in the veins of the neck and 
liver. 

Physical Signs. — 1. Inspection, (a) A positive (systolic) pulse in 
the jugular veins is absolutely pathognomonic and is due to systolic 
entrance of blood into the veins from the right ventricle through the 
insufficient valves. It is presystolic-systolic and is known as positive to 





Fig. 24. 






>» . ^. h 




CO 

< 

o 

< 
z 


fl k "A" 

/A \ j^-k / \ i a / A 


i iv/, if -\ c j 

Iv - \0 \J 

a 


L. v ; v 



Negative (diastolic-presystolic) venous pulse. (After Riegel and Sahli.) 

differentiate it from the negative or diastolic venous pulse which is 
observed in many other conditions, and is eitherphysiological,asondeep 
inspiration caused by temporary damming back of the blood by the 
auricular systole, or pathological, as in stasis. It is seen best on the right 
side because of the more direct (vertical) connection with the right 
innominate vein. A certain degree of heart force is necessary for its 
production, and it may cease therefore when the heart grows weak. 
Digitalis may cause it to reappear in cases of relative and sometimes of 
organic leakage. It is best seen when the patient is in the dorsal decu- 
bitus. To avoid confusion with pulsation transmitted from the carotids, 
the carotid should be compressed as low down as possible, or the pul- 
sating jugular vein should be compressed at the middle; the upper part 
will then pulsate if the carotids beat against it (transmitted pulsation) 
and the lower part will beat if the pulsation is in the vein itself. Though 

Fig. 25. 




Positive (presystolic-systob'c) venous pulse. (After Riegel.) 

it is seen most advantageously in the internal jugular vein, it is some- 
times seen in the vena cava inferior or in the veins of the chest and 
extremities. It is difficult to determine when the heart is rapid or irreg- 
ular, (b) A liver pulse, systolic in time, venous regurgitant in origin, 
is also pathognomonic of this disease, (c) The right heart pulsates 
widely, while the apex beat is weak. 



416 



DISEASES OF THE CIRCULATION 



2. Palpation. — (a) This aids in determining the systolic phase of 
the venous pulse, and (b) it establishes the systolic venous pulsation of 
the liver, which expands in the bimanual examination. It is easier to 
find, and often earlier to appear than the jugular pulsation. It must 
not be confused with an arterial liver pulse, which occurs in cases of 
aortic leakage, exophthalmic goitre, and of liver inflammation, but is 
less expansile than throbbing, (c) A systolic thrill over the tricuspid 
area; (d) tones or thrills over the peripheral veins; and, (e) & weak 
apex and radial pulse are also found. 

3. Percussion. — This shows increased dulness to the right, from 
distension of the right auricle and ventricle. Changes in the left heart 
may indicate an older valvular lesion which leads up to the tricuspid 
leakage. (See Plate VIII, Fig. D.) 

4. Auscultation. — (a) A systolic murmur' is heard over the tricuspid 
region ; it may have a different quality from that of the causal mitral 
lesion. Unlike the murmur caused by mitral lesions, it is rarely heard 



Fig. 26. 




Illustrating the influence of respiration on the positive (presystolic-systolic) venous pulse of the 

j ugular vein . ( After Ko vacs . ) 

in the back. The murmur is absent when the right heart is weak, be- 
cause it then fails to produce the necessary vibration or eddy, (b) The 
second pulmonic sound is weak because the pulmonary circuit is poorly 
filled. This tone often varies with the changing activity of the right 
ventricle. It may remain accentuated even with tricuspid leakage 
when the ventricle is fairly strong, (c) Over the cervical veins may be 
heard a systolic tone referable to closure of valves in the veins; or the 
tone may be double, or presystolic-systolic; or venous murmurs may 
take the place of the single or double tone. 

Diagnosis. — An isolated lesion is most rare. The relative insuffi- 
ciency is diagnosticated by means of (a) the etiology, (b) the large right 
heart, (c) the systolic murmur, (d) the positive venous pulse in the 
neck, and (e) the weak second pulmonic tone. Even when tricuspid 
incompetency is apparently the only lesion, it should be remembered 
that rest or digitalis very often brings out a causal mitral lesion. Much 
is said regarding the "safety valve" action of the tricuspid valves, 
which is hard to understand. Guarding as they do the door between 
the venous, and arterial circulation, their insufficiency indicates most 
serious cardiac failure. 



TRICUSPID STENOSIS 417 



X. Tricuspid Stenosis. 

Tricuspid stenosis is rarer than tricuspid insufficiency; it occurs 
alone in only 10 per cent, of the cases; it is often associated with in- 
sufficiency, or with mitral or aortic stenosis. Obstruction of this 
orifice induces hypertrophy and dilatation of the right auricle, and 
this produces dulness to the right of the sternum. In the single lesion 
the other heart chambers and the large vessels are small. The pulse is 
weak. The second pulmonic sound is weak; a diastolic or presystolic 
murmur and thrill to the right of the sternum are detected if the heart 
is sufficiently strong, but they are often absent. The lesion is most 
serious, because it taxes the weak auricle and greatly engorges the 
venous system. The diagnosis is most difficult; indeed it is usually 
impossible. (See Plate VIII, Fig. D.) 



XI. Combined Valvular Lesions. 

These occur in 33 per cent, of valvular cases. From an anatomical 
standpoint, a pure lesion is rare, and double lesions are found oftener 
than physical signs would indicate. Pure lesions occur most often 
on the arterial valves. One lesion may follow another; for instance, 
stenosis may gradually result from insufficiency sometimes with good 
results; or combined lesions may develop simultaneously. 

(a) Combined mitral lesions are most frequent, though one lesion 
usually predominates; (6) combined mitral and aortic lesions, e.g., 
aortic vegetations reaching the nearest mitral cusp, are next in fre- 
quency and include 71 per cent, of the cases of combined lesions; (c) 
double aortic lesions are less common; id) combined aortic, mitral and 
tricuspid lesions, e. g., stenosis of each orifice with no signs other than 
slowing of the circulation, occur in 16 per cent., and (e) combined mitral 
and tricuspid lesions (especially relative tricuspid insufficiency) occur 
still less often (in 9 per cent.). 

Diagnosis. — The diagnosis depends upon the character of the pulse, 
the quality and direction of transmission of the different murmurs, 
and the hypertrophy and dilatation of the right or left heart. Skoda's 
rule was that a murmur is usually most intense at its point of origin 
except in cases of aortic insufficiency; and Oppolzer held that when 
listening to the mitral and pulmonary valves, murmurs transmitted to 
them disappear as examination is made more to the left, though mur- 
murs due to lesions on these valves remain; on listening further to the 
right, the true tricuspid and aortic murmurs remain and those which 
are transmitted disappear. In diagnosis, the seeking out of the main 
lesions and the avoidance of too complicated diagnoses lead to the most 
practical results. 

In cases of combined aortic and mitral disease: (a) Aortic insuffi- 
ciency and mitral insufficiency lead to dilatation and hypertrophy of 

27 



418 DISEASES OF THE CIRCULATION 

both ventricles; the combination is frequent in children; the aortic 
findings as to pulse are frequently modified: the mitral insufficiency 
may be relative (muscular) or organic (valvular), and this can be 
determined by close and continued observation only. (b) Aortic 
stenosis and mitral insufficiency is next in frequency and is the most 
common combination in adults ; less blood reaches the arteries than in 
simple aortic stenosis; the right heart suffers disproportionately, 
whence the severity of this complication. The systolic murmurs 
usually vary from each other in location, transmission, and quality, 
(c) Aortic insufficiency and mitral stenosis is a relatively frequent and 
favorable combination, because the left ventricle is usually less dilated; 
both may produce presystolic apical murmurs and therefore the state 
of the right heart and the second pulmonic tone are all-important 
diagnostically. (d) In combined aortic and mitral stenosis, the greater 
the aortic stenosis, the more is the hypertrophy of the left ventricle; 
the more dominant the mitral stenosis, the less is the hypertrophy of 
the left ventricle, and the greater is the dilatation and hypertrophy of 
the right ventricle. Differentiation is often difficult. 

General Symptoms of Valvular Disease. — The heart possesses not 
only a certain reserve power but in favorable instances its musculature 
hypertrophies. Symptoms may easily be lacking in the early stages, 
but later compensation to meet the lesion may fail, either tempor- 
arily ("disturbed compensation "), or permanently ("loss or rupture 
of compensation"). This is the asystolie of French writers. Every 
hypertrophy is more or less temporary in its compensation, and ulti- 
mate cardiac failure is inevitable. All lesions, practically speaking, 
tend to reduce arterial tension, increase venous pressure, retard the 
capillary flow and promote embolism. Circulatory disturbances may 
be spontaneous or induced by psychical excitement, physical exertion, 
intercurrent disease, recurrent endocarditis, malnutrition, excessive 
use of alcohol or tobacco, or changes in the heart muscle. The gen- 
eral symptoms and physical findings are more or less common to all 
lesions, but some are more frequent in certain forms of valvular 
disease. 

1. Constitutional Symptoms. — Anaemia is frequent (aortic insuffi- 
ciency); polymorphonuclear leukocytosis is present in half the mitral 
cases; Andral spoke of a "heart cachexia"; the body temperature is 
normal or subnormal from slow circulation. Fever is due to recurrent 
endocarditis, embolism, or intercurrent disease. The nails are often 
clubbed in congenital lesions. Skin hemorrhages are due to " blood 
dissolution" or less frequently to embolism. 

2. Cardiac Signs and Symptoms. — Apart from actual change in the 
chambers, such as dilatation and hypertrophy, the heart itself is not 
well nourished in "breaking compensation," for it receives less arterial 
blood and is engorged with venous blood. The heart muscle is in some 
cases fatty, and in others is the seat of myocarditis about the arteries or 
some cyanotic induration about the veins. These changes are less the 
cause than the effect of lack of compensation; the autopsy and the 



GENERAL SYMPTOMS OF VALVULAR DISEASE 



419 



microscope may fail to demonstrate the cause of broken compensation. 
Here and there pressure atrophy occurs, as in the papillary muscles 
(aortic regurgitation). The rhythm is frequently disturbed, especially 
in mitral lesions (stenosis). The sphygmograph sometimes shows 
two ventricular contractions occurring very close together (pulsus 
bigeminus); when the pulse intermits to the finger, the tones of the 
abortive contraction may be heard over the heart with the stethoscope, 
the weaker wave failing to reach the periphery. In general, the pulse 
beats are fewer than the heart beats. Four tones corresponding to the 



Fig. 27. 




Pulsus bigeminus. 



two heart beats are sometimes heard. The gallop-rhythm (Bouillaud 
1847) is sometimes heard. There may be such irregularity that tones 
and murmurs are indistinguishable (delirium cordis). The pulse is 
slow (the bradycardia of aortic stenosis) or faster than normal, tachy- 
cardia (mitral lesions). 

Among the complications are pericarditis (aortic lesions) and re- 
current endocarditis. Palpitation is frequent, either continuously or 
intermittently, and is sometimes induced by lying on the left side. It 
may be absent with the greatest heart alteration (as in aortic insuffi- 
ciency). A sense of tension over the heart is not infrequent, and pain 
like that of angina pectoris occurs in aortic oftener than in mitral disease 
(Nothnagel). 

3. Nervous Symptoms. — These are not frequent. Syncope (aortic 
stenosis especially) occurs from arterial anaemia of the brain. Venous 
congestion is evidenced by repeated epistaxis, or vertigo, tinnitus, or 
musc& volitantes. Brain hemorrhage is infrequent (mostly in aortic 
insufficiency). Chorea, epileptiform seizures, and embolism of the 
Sylvian arteries are sometimes observed as well as psychoses; the 
latter are delirium, mania, melancholia, and suicidal tendencies, and 
are usually of unfavorable import; stasis, inanition, carbon-dioxide 
narcosis and renal inadequacy are their cause. Retinitis hemor- 
rhagica and simple hemorrhages result from stasis and anaemia. 

4. Respiratory Symptoms. — Lung stasis is sometimes confused with 
independent lung disease on account of dyspnoea, cough, and expectora- 
tion. Cyanosis occurs more often in mitral than in aortic disease and 
is most intense in lesions of the pulmonary orifice. Bronchitis and 
haemoptysis are most common in mitral affections. Bronchitis results 
less from congestion in the lesser circuit than from congestion in the 
cava superior, into which (and the azygos) the bronchial veins empty. 



420 DISEASES OF THE CIRCULATION 

Though usually bilateral, it may predominate on one side, from such 
local causes as pleural adhesions. Haemoptysis results from lung 
stasis with vessel rupture, or from embolism emanating from right- 
heart clots or thrombosis in the pulmonary and less frequently in the 
peripheral veins. The sputum may resemble that of pneumonia, 
though it is darker, more venous, and less viscid. It contains the so- 
called " heart disease cells " (E.Wagner). They are large granular deli- 
cate cells with oval nuclei, which often contain hemosiderin or more 
rarely needles or plates of hsematoidin; they are probably alveolar 
epithelial cells (possibly leukocytes) and also occur in other lesions 
than brown induration (as emphysema, asthma, pneumonia, and 
phthisis). See Plate IX. Pulmonary oedema is either (a) due to weak- 
ening of the left ventricle while the right heart beats more strongly 
or (b) far less frequently is inflammatory. Crepitant rales are fre- 
quently heard. In mitral disease the lungs frequently become dis- 
tended and rigid from engorgement of the capillaries, and somewhat 
resemble the lung in emphysema (von Basch's Lungenschwellung 
und Lungenstarrheit) . Brown induration (cyanotic induration) of the 
lungs has for its anatomical basis, (a) capillary engorgement often with 
fatty change in the intima, (b) increased inter-alveolar and peri- 
vascular connective tissue, (c) hemorrhage into the lung from vessel 
rupture, (d) consequent pigmentation by the altered blood-pigment of 
the lungs and sputum, and (e) the "heart-disease cells." Dyspnoea, 
the "cry of distress of the myocardium" (Sansom), constant, inter- 
mittent, or nocturnal, is caused by unbalanced slow circulation, the 
bulging of the turgid capillaries into the alveoli, pressure of the heart 
on the lower left lobe or left bronchus, ascites, hydrothorax, oedema, 
bronchitis, or infarcts. It may come on even without effort on the part 
of the patient when there are constipation and poor digestion; or it 
may occur especially at night when the voluntary deep and diaphrag- 
matic respiration of the waking hours is not in play, whence the respira- 
tory centre becomes anaemic. The dyspnoea is not expiratory as in 
asthma but is mixed in type (see Caediac Asthma under Cardiac 
Neuroses.) The wheezing which is heard is due to pulmonary oedema. 
The gallop-rhythm is rarely absent, and this threatens relapse of the 
dyspnoea. Arteriosclerosis and nephritis are important elements in its 
production. Exertion not only increases the heart's work but the 
carbon dioxide and fatigue substances from the muscles irritate the 
respiratory centre, and the respiratory muscles ultimately become 
tired. The breathing is more rapid. It may be Cheyne-Stokes in type 
(aortic stenosis); cerebral anaemia, arteriosclerosis, and uraemia are 
its causes. Hypostasis and lobular pneumonia may develop. Hydro- 
thorax may hasten death within a few hours (Andral). 

5. Gastro-intestinal Changes. — Gastralgia, anorexia, hemorrhagic 
infiltration and erosion, vomiting or haematemesis, result from passive 
congestion and may be mistaken for independent gastric disease, such 
as cancer or ulcer. Delayed digestion and constipation are usual. 
The secretion of hydrochloric acid is normal except in cases of marked 



PLATE IX. 







Heart Disease Cells, showing Alveolar Epithelial Cells, Loaded 
Down with Granules of Haematin. (Simon.) 



GENERAL SYMPTOMS OF VALVULAR DISEASE 421 

weakness of the heart. Intestinal hemorrhage may result from capillary 
congestion, rarely from embolism of the mesenteric artery, and most 
infrequently from mesenteric venous thrombosis. 

6. Changes in the Liver. — The liver suffers stasis through the con- 
gested cava and hepatic vein; this leads to cyanotic distention of the 
central veins of the liver lobules (appearing dark) and to cloudy and 
fatty degeneration of their periphery (appearing lighter), the " nutmeg 
liver." This occurs particularly in mitral disease. The liver is not 
uniformly affected. Pigmentation occurs and connective tissue 
develops in the liver and its capsule (perihepatitis, "iced liver"). 
Small granulations develop on its surface and in some instances a liver 
shrinkage results from "cyanotic induration" (cardiac cirrhosis, 
chronic central red atrophy). The liver is symmetrically large before 
oedema appears; when disturbed compensation is being restored, it is 
one of the last symptoms to disappear. Occasionally, from local 
changes, there may be tumor-like enlargement of the liver, which may 
simulate cancer. There is a feeling of tension and weight in the right 
hypochondrium and the organ is tender and variable in size; it may 
become smaller from rest or from administration of digitalis. Its edge 
is rounded and not hard except in the late stages. (See Differential 
Table of Hepatic Diseases). The icterus viridis develops gradually 
and is a combination of mild icterus and cyanosis; icterus is rarely 
intense but is of the "urobilin" type; it is rarely sudden except in the 
infrequent embolism, which may cause a clinical picture resembling 
acute yellow atrophy. Ascites is usually late and secondary to the liver 
congestion; its early appearance is indicative of independent liver 
disease or peritoneal affections. It is sometimes chyliform. 

7. Changes in the Spleen. — The spleen is sometimes increased from 
embolism or liver disease, but is often harder and smaller than normal. 

8. Changes in the Kidneys. — The kidneys are enlarged from hyper- 
emia, the capsule strips readily, and scattered areas of blood extrava- 
sation are seen. The stellular Verheynii are prominent, as also are the 
glomeruli. Some epithelial degeneration from malnutrition is seen and, 
in cases of long standing, "cyanotic induration" occurs. Deformity 
from the stellate scars of healed embolism and fresh infarcts are often 
encountered. 

Renal symptoms are greater, the higher the venous and the lower 
the arterial blood pressure. The urine is decreased — its daily amount 
being an accurate gauge of the heart's force; it is of higher specific 
gravity (1025 to 1030), very acid, and is highly colored from urates and 
increased uric acid (even an eight-fold increase) ; the urea is decreased 
and also the chlorides when oedema exists; albumin is frequent (at 
the most 2 per l,000[Krehl]),and there may possibly be a few red disks 
though these are more usually due to embolism or acute nephritis. 
The kidneys are slow to eliminate methyl blue or potassium iodide. 
Krehl has found granular as well as hyaline casts, contrary to the 
usual experience. (See Differential Table of Diffuse Renal 
Diseases.) Chronic nephritis may coexist. Rest and digitalis 



422 DISEASES OF THE CIRCULATION 

increase the amount of urine and decrease or remove the albumin. 
In women, menstruation is frequently increased by passive congestion. 

9. Embolism. — Embolism occurs as it does in acute endocarditis but 
its significance and effects are wholly mechanical. Embolism occurs in 
about one-third of the cases. Though it is most common in the kidney 
(77 per cent.) and spleen (54.7 per cent), it also occurs in the arteries 
of the brain (22.7 per cent.) (left Sylvian artery), in the extremities 
especially, in the branches of the left iliac artery, in the retina, liver, aorta 
(with paraplegia), and mesenteric vessels (in 1 per cent.). In the lungs 
it results from right-heart clots or thrombosis in the large peripheral or 
pulmonary veins. The special visceral features of embolism will be 
discussed under Diseases of the Brain, Lung, Kidney, etc. 

10. (Edema. — This is a result of venous stasis, transmitted to the 
lymph-vessels and interspaces, and is also an evidence of changes in 
the vessel walls from actual blood alteration, for in some cases at least 
the blood is thinned (hydremia). It appears first in the connective 
tissue of the lower extremities (right leg); it disappears over night; 
and it extends upward to the vulva or scrotum, abdomen, chest and 
serous sacs (ascites, hydrothorax and hydropericardium) and brain ven- 
tricles. The loss of fluid to the system is unfavorable; the anasarca also 
impedes the arterial circulation, threatens life from involvement of the 
glottis or lungs, increases the tendency to secondary infections (erysipe- 
las, cellulitis, ulceration, or gangrene) and may lead to hypertrophy of 
the connective tissue about the genitalia (cardiac elephantiasis). It is 
most common in mitral disease. The prognosis is less favorable if the 
liver becomes very large before oedema appears. 

11. Changes in the Joints. — Swollen joints and tabes dorsalis (aortic 
insufficiency), are occasionally associated with valvular disease. 

Course and Prognosis of Valvular Disease. — Patients may live for 
years with compensated valvular affections; a case of aortic leakage 
lived for twenty-five years and a case of mitral leakage lived for sixty- 
six years. As a rule the course is chronic and unfavorable, and is 
influenced by the following conditions: — 

1. State of the Heart Muscle. — This muscle is the basis of hyper- 
trophy and compensation. Myocarditis is most unfavorable whether 
associated or not with coronary disease, for digitalis has then no effect 
on the heart muscle. In cases where digitalis has immediate effect, the 
prognosis is favorable. The size of the heart is more important than 
valvular murmurs. Great dilatation or dilatation without hypertrophy 
is most unfavorable. 

2. Sex; — The prognosis is generally better in women, because they 
are less exposed and less subject to physical strain and coronary 
disease. Pregnancy as a rule is a rather unfavorable complication. 
Peter advises, "In girls, (with valvular lesions) no marriage; in wives, 
no pregnancy; in mothers, no nursing." 

3. Age. — In the first decade of life the prognosis is poor, even though 
the heart and coronary vessels are young, because hypertrophy and 
dilatation are extreme, exercise is difficult to regulate, the valvular 



GENERAL TREATMENT OF VALVULAR DISEASE 423 

lesion tends to recur and the endocarditis tends to develop into peri- 
carditis or pancarditis. After puberty the outlook is better, except, of 
course, in congenital types. . 

4. Valve Involved. — Opinions vary widely; for instance, aortic in- 
sufficiency is rated as the most favorable form by some, and as the most 
unfavorable by others. This may depend on the type, the outlook 
being fair in the endocarditic and most ominous in the atheromatous 
type. The best clinicians disagree as to the relative outlook in mitral 
and aortic lesions, although subjects of mitral insufficiency seem to 
have the more favorable prognosis. Broken compensation is more 
likely to be restored in mitral insufficiency than in mitral stenosis or in 
aortic lesions. Mitral stenosis is less favorable, although it is often 
found in women at an advanced age. Aortic stenosis is also found at 
an advanced age. Combined or multiple lesions, with some few 
exceptions, are unfavorable. The writer observed, in a young physi- 
cian, a complete recovery from a double mitral lesion; in eight years 
after his causal rheumatism the outlines and tones became perfectly 
normal. Pulmonary lesions give a tendency to early tuberculosis. 

5. Mode of Life. — The social scale, hygiene, necessity of hard work, 
psychical excitement, alcoholism, exposure, and the individual consti- 
tution, are most important factors. 

6. Unfavorable Symptoms. — Cardialgia, angina pectoris, embolism, 
persistent palpitation, dyspnoea, and irregular or intermittent pulse are 
unfavorable symptoms. The "reserve heart power " of Martius is 
not present in all cases ; this is due to failure of the coronary vessels 
to increase their calibre (Verney). 

7. Favorable Conditions. — As described by Sir Andrew Clark, these 
are good general health, just habits of living, and absence of special 
rheumatic or catarrhal tendencies, endocarditic (not atheromatous) 
origin, no changes in the heart after three years' observation, sound 
ventricles and arteries, and freedom from stasis in the lungs, liver, and 
kidneys. 

8. Sudden Death. — In most cases, sudden death occurs in aortic 
affections from coronary disease, but it may also result from cerebral 
or pulmonary embolism, from thrombosis cordis occluding an orifice, 
from heart rupture, from sudden ventricular dilatation, and from 
glottis oedema. 

9. Intercurrent or Associated Disease. — Tabes and chorea have 
been mentioned. Valvular disease does not exclude cancer nor typhoid, 
as was once claimed. The acute fevers greatly tax the myocardium. 
Tuberculosis, which is said to be rare except in pulmonary valve lesions 
(since the lungs are hypersemic), is found in 8 per cent, of autopsies on 
valvular subjects. 

Treatment of Valvular Disease. — (A) In Compensated Lesions — 
In compensated lesions medicinal treatment is usually unnecessary 
With some exceptions, the patient is informed of the nature of his 
trouble that his cooperation may be enlisted. The mode of life is 
important, i. e., regular orderly living, as free as possible from psychi- 



424 DISEASES OF THE CIRCULATION 

cal or sexual excitement, worry, or hurry. Especial care should be 
enforced in aortic cases because of danger of sudden death. Much 
depends on the social status of the patient. Plenty of sleep is advisable, 
although heavy sleep after meals is said to promote fatty degeneration. 
The diet should be simple but not too schematic. Tobacco should be 
interdicted, but like alcohol can sometimes be given with care and 
moderation; beer and champagne are but poorly tolerated, though 
some red wine and brandy or cognac are permissible, especially in 
adults and in the aged. Coffee may be given in the morning but should 
not be strong, for cardiac irregularity frequently results. A breakfast 
of milk, with a little liquor, may be taken before rising, and the noon 
meal should be the heartiest of the day. Nitrogenous food is best, 
with such light carbohydrates as toast; foods which ferment, such as 
cabbage, beans, or brown bread, should be avoided and the amount of 
fluid ingested should be moderately restricted. Those things which 
load the stomach heavily, are prone to elevate the diaphragm, and 
every meal somewhat taxes the heart. A light meal at night is the best 
precaution against gastric and cardiac oppression during the sleeping 
hours. A milk diet is recommended in cases of stasis, especially when 
there is much hepatic congestion, but it necessitates the ingestion of too 
large quantities of milk. 

Exercise. — Exercise must be rational, and in moderate cases is advis- 
able, for the muscles can not only accommodate all the blood of the 
body, but also by their activity reflexly stimulate the heart muscle. 
Palpitation, recurrent endocarditis and intercurrent fever necessitate 
keeping the patient in bed. Moderate massage is beneficial, but care 
must be taken lest it produce dilatation of the abdominal vessels. 
Deep breathing and singing are also beneficial. Plethoric patients 
should be given an enema of salines, which should be allowed to re- 
main in the bowels over night. Tepid baths are more beneficial than 
those which are cold or hot. 

Climate. — High altitudes are to be avoided, although moderate 
elevation is tonic. The seashore often disagrees with rheumatic or 
catarrhal subjects. A warm climate should be chosen for the winter. 

(B). Broken Compensation. — Broken compensation may be acute, 
gradual or terminal, as by coronary occlusion, and is evidenced by 
dyspnoea which develops on exertion or spontaneously during the 
night, by anaemia, by irregular pulse (of special significance in aortic 
cases), and by dilatation. The indications are as follows: 

1. Absolute Rest in Bed. — This is frequently curative, especially 
in chlorosis or in pregnancy. Some patients are obliged to sit up 
because of dyspnoea. Liebermeister's case of severe cardiac disease 
which recovered while in bed with a broken leg, is an example of com- 
pensation restored without digitalis or other drugs. Rest is imperative 
in intercurrent fevers, bronchitis, recurrent endocarditis, and acute 
cardiac insufficiency. Bed sores can be prevented by the use of water- 
cushions, and by cleanliness. The head may be propped up by back- 
rests, but they should have side supporters so that falling to sleep will 



GENERAL TREATMENT OF VALVULAR DISEASE 425 

not waken the patient. Rest should be combined with purgation (see 
below). 

2. Saline Purgation. — Epsom or Glauber salts gss-j in con- 
centrated form should be given in the morning or compound jalap 
powder 3 ss -j at night. These and kindred remedies deplete or 
bleed, as it were, the portal circulation and relieve the heart. Consti- 
pation per se often increases the size of the left heart. 

3. Venesection. — This is necessitated by extreme venous engorge- 
ment evidenced by cyanosis, orthopncea, dilatation, or tricuspid leak- 
age. Six ounces to nearly a quart may be drawn. The effects are 
too often considered transient although the symptoms return sooner 
or later. In two cases apparently dying of valvular disease, where 
no blood could be obtained from the arms, the external jugular veins 
were opened, and the patients lived more than a year afterward. 
Venesection is not to be left until the patient is in extremis. It may 
be necessary to have the patient "actively move the arm so as to 
bring the blood from the capillaries into the veins" (Liebermeister). 

4. The Oertel and Schott Methods. — (See Treatment of 
Disease of the Heart Muscle.) 

5. Digitalis. — Digitalis was first recommended by Withering, and 
its physiological action demonstrated by Traube. Its general indi- 
cations are (a) dilatation: digitalis gives or restores tone to the heart- 
muscle and its ganglia, and upon these the drug exercises its main 
influence; (b) functional dissociation: it is claimed that the ventricles 
have different innervation and that the drug is used most efficaciously 
when the pulmonary and venous circulations are engorged from too 
weak systole of the right and too strong systole of the left ventricle. 
When the pulse is irregular, digitalis coordinates the cardiac energy 
by action on the heart muscle and its ganglia or upon the terminal 
branches of the vagus, (c) Rapid, weak, heart action: digitalis slows 
the heart by action on the vagus and by increasing arterial pressure. 
It tends to abolish abortive cardiac contractions (v. s. pulsus bige- 
minus), and synergizes the systole of the chambers, as is shown by 
the strong systolic spasm of the heart in cases of digitalis poisoning. 
The slower and stronger systole empties more completely all the heart- 
chambers, forces the venous and arterial blood into the main arteries, 
and squeezes the venous blood out of the heart muscle itself, thereby 
improving the intrinsic heart circulation. The slower and more 
complete diastole allows of better filling of the heart and drainage 
of the engorged veins. Digitalis raises the arterial tension by increas- 
ing the working power of the heart and by its centric and local action 
on the vasomotors. 

In the individual lesions: (a) in mitral stenosis, the longer diastole 
drains the left auricle and lung vessels and the stronger systole forces 
the retarded blood through the stenotic orifice; (b) in mitral insuffi- 
ciency, the best results are obtained; the leaking cusps are better 
coapted and the stronger systole fills the aorta and pulmonary artery; 
(c) in aortic stenosis, when dilatation occurs or the hypertrophy is 



426 DISEASES OF THE CIRCULATION 

inadequate, digitalis is valuable; (d) in aortic regurgitation, it is theo- 
retically contraindicated since it increases the diastole and hence the 
leakage; it is however practically valuable. 

Digitalis is contra-indicated (a) in balanced compensation; (b) in 
adequate hypertrophy; (c) unless rest and purgation have first been 
tried ; (d) when the vessels are fragile, as in aneurysm and advanced 
atheroma (on account of danger, e.g., of brain hemorrhage); (e) in 
fatty degeneration of the heart, except when resulting from stasis and 
malnutrition; (/) in vascular contraction. It is in this case combined 
with nitroglycerine, strophanthus or potassium iodide, for the purpose 
.of "unlocking the arteries" (Balfour). The drug is not absolutely 
contra-indicated in the high tension of arteriosclerosis and nephritis, 
for it may relieve the condition, paradoxical as this may seem, by 
lessening dyspnoea and carbon-dioxide narcosis, (g) In idiosyncrasy 
to the drug, e.g., when there are gastrointestinal symptoms which, how- 
ever, are more often due to stasis. Digitalis also causes contraction of all 
unstriped muscular tissue (gastric, muscular). It may cause insomnia, 
delirium, headache, diplopia, blindness to green colors, etc. Digitalis 
is said to dilate the left and contract the right coronary artery; there- 
fore when the right coronary vessel is diseased, it may dilate, and 
cause excessive contraction of the right ventricle and thus dissociate 
the heart's action. 

Cumulative action is averted (a) by intermittent administration,, al- 
though some patients tolerate digitalis continuously for months or 
years, as Thomeyer's case who used digitalis eight and a half years, 
taking in all over 15 ounces of the solid digitalis; (b) by great care in 
ambulatory cases; (c) by care in cardiac dropsy, on relief of which 
toxic quantities may be resorbed from the tissues; (d) by care in in- 
tercurrent febrile affections, for toxic effects often follow the fall of 
temperature; (e) by withdrawal on the appearance of vomiting, 
syncope, reduced urine or irregular pulse (with twice as many heart 
as pulse beats). Twenty-seven cases of pulsus bigeminus from the 
use of digitalis are reported. 

Digitalis may fail to operate unless free purgation, venesection, and 
mechanical removal of the anasarca have been first employed. 

Preparations. — Some physicians prefer the powder, gr. j, others the 
tincture, ttjjxv to xx, or the infusion 5 ss ~j- The infusion is considered 
more diuretic (containing digitalein and digitonin). 

Infusi digitalis Siij- 

Spts. setheris nitrosi 5j- 

Potas. bicarbonatis 3ss. 

Aquae 5ij. 

S. — To be taken after meals. 

Larger doses may be given though with risk. It is excellent for rectal 
use when the stomach is irritable. The tincture is thought to be the 
best cardiant because it contains digitalin and digitoxin. The writer 
has found digitalin almost inert. Digitoxin has seemed of doubtful 



GEXERAL TREAT MET OF VALVULAR DISEASE 427 

value, but in the author's hands it has often slowed and strengthened 
the weak and irregular heart (gr. T ^ 6 1. i. d.), when digitalis has failed; 
it easily disorders the stomach, and often cannot be given for more 
than six or eight doses. Digitoxin is often advantageously combined 
with champagne. For hypodermic use, the fluid extract, Tn?ij to iv, is 
a non-irritant. Cloetta's digalen is a soluble non-irritant digitoxin, 
and may be given intravenously, 1 c.c. equalling 0.3 mg., or r |o 
grain. The writer believes the preparation acts promptly, though it 
is somewhat irritating when given hypodermatically. 

6. Other Cardiants. — (a) Strophanthus , tt#v to x of the tinc- 
ture every eight hours, may be given. Advantages: it is more rapid 
in action than is digitalis, has no cumulative effects, perpetuates the 
effects of digitalis after the first five or seven days, and is indicated 
especially in the irregular heart of mitral disease, in children under 
twelve years, in cases where we are waiting for the digitalis to act, and 
in dilatation where the blood pressure is high. Disadvantages: it is 
less certain and less energetic; it is inferior in oedema and does not 
give tone to the vessels (which may be an advantage in atheroma). 
(b) Strychnine stimulates the vagus and heart muscle, besides being 
a splendid vascular tonic (see Pneumonia, Treatment) and tonic 
to the nervous, gastric, and blood-making tissues. Given carelessly, 
it may irritate the heart, decrease the urine by spasm of the renal 
vessels, or even induce rupture of the vessels, (c) Spartein sulphate 
(gr. J to \ every six or eight hours) is given in capsule because of its 
bitterness; larger doses may be given, gr. j to gr. iss; it seems to quiet 
the nervous system and regulate the heart better than other remedies 
(See) but is very inferior to digitalis. It does not contract the ves- 
sels. Convallaria and adonis are very unsatisfactory. 

7. Symptomatic Treatment. — (a) Dropsy. — Saline or hydragogue 
catharsis often relieves moderate oedema. Digitalis, alone or com- 
bined with calomel or blue mass, and pulv. scillse (Guy's pill) is often 
efficacious — 

Pulv. digitalis gr. x. 

Massse hydrargyri gr. vj . 

Pulv. scillae gr. x. 

M. et ft. capsulse x. 
S. — One after meals for one or two days. 

Mercurials, which were recommended by Jendrassik, must be used 
with the greatest care. The author saw, in consultation, a case com- 
plicated by nephritis in which the tongue sloughed off after five grains 
of calomel had been given. Desperate stomatitis may result in alco- 
holic, myocarditic, or nephritic subjects. Excess of digitalis, it must 
be recalled, is held to suppress the urine by inducing renal spasm. 
It is better to use potassium salts, as potassium acetate gr. xxx, t. i. d., 
which are less abundant in the tissues than the sodium salts; the 
potassium acetate, e. g., passes through the tissues and kidneys, taking 
fluid with it (Bunge). Huchard proved that the diuresis following 



428 DISEASES OF THE CIRCULATION 

digitalis was associated with increase of sodium chloride elimination. 
Caffeine with digitalis is beneficial in dropsy when the pulse is slow, 
the mind dull, and the digestion sluggish; it may cause nervousness 
or insomnia (therefore should be given early in the day), irregular 
pulse (therefore should be combined with rum or brandy), or bilious- 
ness; gr. v should be given, but not for more than three days — 

Caffeinse citratse oss. 

Sodii benzoatis oss. 

Aquae 5iij- 

M. et S. — One hypodermicful (3ss), as indicated. 

Diuretin (daily dosage of 60 to 90 grains) may have marvellous effects 
or may absolutely fail; chemically it is sodio-salicylate of theobrom- 
ine; it contains 50 per cent, theobromin, and operates on the renal 
cells directly, and possibly also on the heart and vessels. Canadian 
hemp (fluidextr. apocyni tt£ xv) is hard to obtain pure but some- 
times justifies Benjamin Rush's term, "a vegetable trochar." Sweats 
and the use of pilocarpine are both dangerous and injurious. Mechan- 
ical drainage is recommended, by scarification, by multiple knife or 
pinpricks, or by Southey's capillary tubes; but the best method is 
by a single long deep incision down to the bone. Sodium chloride 
should be excluded from the diet (see Dropsy, Treatment of 
Chronic Nephritis). Ascites, from heart disease alone, rarely 
necessitates puncture : it is indicated chiefly in coincident liver cirrho- 
sis or in chronic peritonitis. Hydrothorax is far more important, and 
thoracic paracentesis should not be delayed when dyspnoea is urgent. 

(b) An&mia. — The administration of digitalis with iron, arsenic, 
and zinc phosphide often produces remarkable improvement; iron 
and arsenic may be useful without employing digitalis at all. 

Pulv. digitalis gr. xx. 

Ferri redacti oss. 

Ac. arsenosi gr. j. 

Zinci phosphidis gr. j . 

M. et ft. pilulae, xx. 
S. — One pill after meals. 

Cod-liver oil is excellent in children. 

(c) Insomnia. — It is often difficult to relieve insomnia or unrestful 
sleep, broken by nightmare or sudden "heart starts." Spts. chloro- 
formi, spts. camphorae, and spts. setheris compos, aa 3 SS are often 
helpful. Sulphonal (gr. xx in hot milk at bed-time) may be tried but 
is somewhat dangerous in stasis; not more than three doses should be 
given. Chloralamide may be tried, but morphia is most efficacious. 

(d) Dyspn&a. — The ice-bag, quinine and nitroglycerine gr. T ho 
(though it gives better results in 5 per cent, alcoholic solution), are 
of value for high tension. Morphine may be given in the early stages, 
and without hesitation, and especially at night, for restlessness and 
dyspnoea; it is excellent while waiting for digitalis to act. It is almost 



GENERAL TREATMENT OF VALVULAR DISEASE 429 

specific and lessens the irritability of the respiratory centre. It is 
dangerous when the heart weakens, the lungs become ©edematous, or 
Cheyne-Stokes breathing is present. Dyspnoea is often renal or due 
to (right-sided) hydrothorax, chronic bronchitis, or excessive dilata- 
tion, and appropriate treatment is indicated by catharsis, paracentesis, 
potassium iodide, or digitalis, respectively. 

(e) Cardiac Symptoms. — Cough, cyanosis, pulmonary oedema, and 
haemoptysis are usually true cardiac symptoms, and have for their 
anatomical basis pulmonary engorgement or brown induration; they 
are relieved by the cardiants. Balfour recommends the following 
combination for associated bronchial catarrh: 

Ammonii carbonatis 5j. 

Tr. hyoscyami 5iv. 

Potassii iodidi 5j- 

Tr. digitalis 5 j .. 

Infusi calumbse q.s. ad 5vj. 

M. et S. — One teaspoonful every four hours. 

Expectorants usually nauseate. Hsemoptysis is often beneficial; it 
may be regarded as a species of lung venesection and is seldom urgent 
or fatal. For cyanosis, alcohol and camphor are indicated. Pulmon- 
ary oedema necessitates phlebotomy; and a 30-grain dose of lead 
acetate, gr. T ho of nitroglycerine, and gr. \ of morphine should be 
given. 

(/) Palpitation and Pain. — For palpitation and throbbing, the ice- 
bag may be used; a precordial blister, or tapping several times on 
the back, or a few minims of tr. belladonnas and tr. aconiti are 
often helpful. 

Fluidextracti belladonnas gtt. xv. 

Tr. digitalis 3j. 

Aq. laurocerasi .q.s. ad §j. 

M. et S. — One teaspoonful two or three times daily. 

Care regarding the evening meal (see Diet) and the condition of the 
colon is important. Ten grains of iodide of potash with nitroglycerine 
(or gr. ss of erythrol tetranitrate which produces a more lasting effect), 
are valuable for the pain of aortic lesions, especially when these are 
accompanied by weakness, pallor, neuralgia, vertigo, or headache. 

(g) Gastric Symptoms. — These are troublesome and ominous. They 
are largely due to portal stasis, for the liver is enlarged and there is 
usually not much oedema. They are more often caused by stasis 
than by a cumulative effect of digitalis, which should then be given 
by rectum. Small doses of carbolic acid, gr. J every half hour for five 
to ten doses, and rectal nourishment are indicated. 



430 DISEASES OF THE CIRCULATION 



(III). CONGENITAL HEART-DISEASE. 

These cases are infrequent and are usually most complicated. They 
occur largely in the right heart, upon which more work is devolved 
in foetal life. The causes are (a) developmental errors or deficits, and 
these are by far most frequent; (6) foetal endocarditis which is nearly 
always sclerotic and very rarely verrucose; (c) foetal 'myocarditis or 
(d) adult endocarditis developing upon developmental anomalies. They 
are most often seen in male children, and heredity seems occasionally 
a factor. 

1. Pulmonary Stenosis. — This is by far the most frequent con- 
genital lesion and occurs in various forms; (a) stenosis or actual 
atresia of the orifice itself from endocarditis (the orifice closed by a 
diaphragm or ring) or myocarditis. In this form the second pulmonic 
tone is weak or absent, (b) Changes in the conus arteriosus which 
obstruct the onward flow of blood. The second pulmonic sound is 
clearly heard, if the valves are normal. The constriction may cause 
the development of a second ventricle, (c) The pulmonary vessel 
beyond the valves is narrowed or even converted into an impervious 
cord; this is a grave type of pulmonary stenosis. The second pul- 
monic sound is usually heard. 

The physical signs are hypertrophy and dilatation of the right ven- 
tricle, a thrill over the pulmonic area, and a systolic murmur prop- 
agated into the neck when there is a defect in the interventricular 
septum. These cases are more favorable than those in which such 
defect does not obtain, because in them the right ventricle is atrophic 
and the subjects rarely live over a year. In pulmonary stenosis other 
congenital abnormalties are most common. If the closure or stenosis 
exist before the end of the second month of foetal life, the interven- 
tricular septum fails (in 75 per cent, of cases) to close, and is pushed 
to the left, so that the aorta may partly or entirely originate in the 
right ventricle. If the closure develops after the second month, the 
foramen ovale remains patent (66 per cent.). Upon these openings 
acute endocarditis is likely to develop. The ductus Botalli usually 
remains open and thereby conducts blood from the aorta to the pul- 
monary artery and lungs. Should the ductus Botalli and the pulmon- 
ary orifice be closed, collateral circulation is possible through the 
oesophageal, pericardial, and bronchial arteries. The right ventricle 
usually hypertrophies, especially at the conus, but hypertrophic changes 
in this chamber are not constant; the left heart is atrophic. 

2. Defects of the Interauricular Septum. — The foramen ovale is 
open to some extent in 44 per cent, of all autopsies, and the membrane 
is deficient, cribiform, or wholly absent. The foramen ovale usually 
closes in the first week of life, but fails to adhere when low pressure 
in the left auricle exists. Entire absence of the septum is the most 
extreme defect possible; this is called the "reptilian heart," or cor 
biloculare when the interventricular septum is also absent, or the 



CONGENITAL HEART-DISEASE 431 

cor triloculare when the ventricular septum is present. Its patency 
aids compensation in this condition or when the valvular orifices are 
narrowed or closed or when the great vessels are transposed. Symp- 
toms are absent or are those of the more important associated trouble, 
for its patency is almost a necessity in some congenital lesions. Rare 
occurrences are presystolic murmur at the level of the third or fourth 
ribs; "crossed or paradoxical embolism/' which may occur, for in- 
stance, in the brain from venous thrombosis in the leg or even from 
particles of the liver or of neoplasms (the clots or tissue which pass 
directly from the right to the left auricle) ; and positive venous pulse 
in mitral regurgitation. Several cases have been found in living 
subjects over seventy years of age. 

3. Defects of the Interventricular Septum (Maladie de Roger). — 
These have been spoken of under pulmonary stenosis. They may be 
single, associated with other anomalies, or may result from myocarditis. 
Sometimes a canal-like opening connects the aorta with the right 
ventricle. The deficit occurs oftenest in the upper "undefended" 
part of the septum. When it is wholly absent the heart has but three 
chambers, the "trilocular heart" {cor triloculare biatriatum). Symp- 
toms are absent, complicated, or ambiguous. At times the signs are 
those of mitral leakage without the lung symptoms of stasis. A loud 
systolic murmur is heard over the upper third of the precordium but 
does not reach the large vessels. 

4. Patency of the Ductus Botalli. — The duct is usually closed by 
proliferation of its coats within the first month of life, because the 
pulmonary blood-pressure is lowered after birth. Thus premature 
closure follows pulmonary stenosis, which necessitates poor filling of 
the lungs with blood. Permanent patency of the duct is promoted 
by other congenital lesions or by atelectasis or pneumonia in the new- 
born. It leads to increased blood tension in the lung. The second 
pulmonic sound is accentuated, and the artery is frequently dilated, 
whence the dulness in the second left interspace, with thrill, pulsation, 
and loud vibratory systolic murmur which may reach the cervical 
vessels or the fourth dorsal vertebra behind. Sometimes the vessel 
is so dilated as to compress the recurrent laryngeal nerve and thus 
cause hoarseness. The right ventricle is hypertrophied and dilated; 
it is distinguished in clear cases from pulmonary stenosis by the 
greater cyanosis of the latter lesion, the less frequent propagation to 
the neck, and the absence of the second pulmonic sound. 

5. Persistent Isthmus Aortae. — The fcetal, developmental, throm- 
botic or inflammatory narrowing at a point between the left subclavian 
artery and the ductus Botalli (46 per cent, below the duct, 37 per cent. 
at the duct, and 17 per cent, over it), is characterized (a) by hyper- 
trophy of the left ventricle (50 per cent.) to overcome the stenosis, 
and sometimes by a systolic murmur in the interscapular region; [b) 
by largeness and fulness of the aorta above the isthmus, of arteries 
of the head (brain hemorrhage), neck and arms (full radials); (c) 
by a small, retarded, abdominal and femoral pulse, corresponding 



432 DISEASES OF THE CIRCULATION 

to the anatomical smallness of the vessels below the isthmus; (d) by 
a pronounced collateral circulation between the branches of the aortic 
arch and those of the thoracic and abdominal aorta, especially the 
internal mammary, inferior thyroid, and transversalis colli arteries. 
Other anomalies, such as open foramen ovale, are present in 37 per 
cent, of cases. 

The observant pathologist makes the diagnosis at once; he cuts 
through the large vessels in the skin of the chest and abdomen, and 
the clinician when he feels the large vessels (present in 25 per cent, 
of the cases) and the thrill in them or hears their tones and systolic 
(or less often, diastolic) murmur, suspects the lesion. Valvular lesions, 
especially aortic insufficiency, may coexist. Broken compensation may 
intervene, though all cardiac signs may be lacking. Aneurysm and 
mediastinal tumor are frequently confused with it. The aorta some- 
times ruptures. The lesion is nearly twice as common in the new-born 
as it is in adults. Vierordt (1898) collected only 135 cases from the 
literature. 

6. Aortic Atresia or Stenosis. — The lesion is uncommon. The 
conus arteriosus may be greatly constricted. If the lesion is develop- 
mental, the interventricular and -auricular septa are open; if endo- 
carditic or myocarditic, they are closed, provided the lesion develops 
after the third month of foetal life. The left ventricle hypertrophies 
in stenosis or atrophies in atresia, while the right ventricle hyper- 
trophies in order to force the blood from the pulmonary artery through 
the ductus Botalli into the aorta. The lesion may be associated with 
other cardiac anomalies, with myo- or endocarditis, or with chlorosis, 
tuberculosis, or haemophilia. 

7. Mitral Changes.— These are very rare. 

8. Tricuspid Stenosis or Atresia.— This is developmental or inflam- 
matory. In atresia the interventricular and -auricular septa are open 
and the right heart is atrophic. Tricuspid insufficiency is most rare. 

9. Transposition of the Arteries and Veins. — In this lesion the 
foramen ovale remains open; the aorta originates in the right heart. 

10. Valvular Anomalies. — These are largely of anatomical interest. 
The semilunar valves, especially the pulmonary, may be increased 
in number from three to five; or they may be decreased to two, which 
occurs especially in the aortic valves. Whether developmental or 
inflammatory in origin, accessory or abnormal valves are particularly 
prone to acute or chronic endocarditis. 

11. Anomalies in Location and Development. — These are absence 
of the heart, acardia, double heart, or ectopia cordis, where the heart 
lies in the abdomen, or in the pectoral (with fissured sternum) or 
cervical regions. 

Dextrocardia (dexiocardia) occurs with situs viscerum inversus; the 
mitral valve has three cusps, the tricuspid has but two; the pulmonary 
veins empty into the right auricle; the pulmonary artery arises from 
the left, and the aorta from the right, ventricle; the aorta runs to the 
right of the spine, to the right of the oesophagus, and to the left of the 



CONGENITAL HEART-DISEASE 433 

cava; the vena azygos is on the left and hemiazygos is on the right; 
the innominate artery is left-sided; the right lung has two lobes, the 
left three; the bronchial fremitus is greater on the left side, the left 
bronchus being larger; the spleen, liver, stomach, and colon, are 
transposed; the right kidney and testicle are higher than the left. 
The heart alone is rarely transposed. In one case complete trans- 
position of all the viscera except the caecum occurred. 

General Symptoms of Congenital Heart Disease. — Cyanosis is 
present in 90 per cent, of cases whence the name "morbus caeruleus"; 
it is more intense than in acquired lesions. It usually appears early, 
and is either general or limited to the nose, fingers, etc.; the skin 
may be actually purple, and this is due to mixing of the arterial and 
venous currents, to a sluggish circulation in the small veins, or to 
impaired function of the red cells. Some subjects are anaemic, but a 
most striking increase of the red cells up to eight or nine millions 
(polycythemia rubra) is seen in some cases, probably as a compen- 
satory effort. The haemoglobin may register 130 and the specific 
gravity 1,077. Dyspnoea, cough, convulsions, and marked clubbing 
of the fingers and toes, are frequent. The pulse is variable and the 
temperature often subnormal. Mental and physical development is 
incomplete, and exophthalmos, swelling of the face, lips and nose, 
and of the optic disk are frequent. (Edema and stasis are not frequent. 
There is a tendency to hemorrhage and pulmonary tuberculosis. 
Coincident maldevelopment occurs (in 10 per cent, of cases) in other 
organs, such as the stomach, colon, kidney, and spleen; imperforate 
anus, hypospadias, cryptorchismus, polydactylia, hare-lip, spina bifida, 
acrania, anencephalus, and uterus bicornis also occur. The murmurs 
are usually systolic and rough, although very complicated lesions may 
exist with normal heart tones. In a few instances the foetal murmur 
was heard before birth (Peter). The dulness concerns the right 
ventricle chiefly. 

Prognosis. — The prognosis is poor, for the lesion is incurable and 
compensation is incomplete. The patient usually succumbs to cardiac 
failure or to pulmonary tuberculosis (25 to 40 per cent, of cases) 
in the second decade (81 per cent.), hence Rokitansky's rule, that 
cyanosis protects the lungs from tuberculosis, is not absolute. 

Treatment. — The treatment is wholly symptomatic. The body 
should be kept warm; baths should be employed to guard against 
colds; mental and bodily strain should be avoided; and in general 
the therapy of adult valvular disease should be followed, except that 
the heart stimulants must be used with considerable caution only. 



28 



434 DISEASES OF THE CIRCULATION 

DISEASES OF THE HEAET MUSCLE. 

DILATATION OF THE HEART. 

Definition. — Dilatation means distention of the chambers of the 
heart; it may be partial or complete. Hypertrophy is thickening of the 
walls of one or more chambers. The two conditions are quite separate 
in themselves, though they are frequently combined. 

Pathology. — Dilatation occurs (a) with thinning of the walls, simple 
dilatation, or (b) with eccentric hypertrophy (q. v.). It is most common 
in the thin-walled auricles and less resistant right ventricle. The mus- 
cle is lax and the heart, when held inverted by the basal vessels, may 
in extreme instances fall flabbily like a cap over the hand. The dilata- 
tion may be so extreme that the endo- and pericardium almost touch. 

There is much blood in the heart's chambers, in the cavse and other 
veins. Long-standing dilatation is not to be confused with dilatation 
occurring during the death agony from acute lung disease, suffocation, 
etc., in which the right heart is chiefly affected and in which on removal 
of the post-mortem clots the chambers seem more nearly of normal size. 
The papillary muscles and the trabecular are flattened as in aortic in- 
competency (pressure atrophy), and are not infrequently thickened 
(pressure sclerosis). Microscopically the heart muscle may be normal, 
or may show evidences of fatty or cloudy (or amyloid) degeneration, or 
acute or chronic myocarditis. The precise role of degeneration in the 
ganglia of the heart has not been determined. 

Etiology*. — 1. Mechanical Causes. — The normal heart may yield to 
increased blood-pressure or a weak heart may yield to normal pressure. 

The mechanical causes are: (a) Valvular disease, e. g., dilatation of 
the left ventricle in aortic insufficiency, or of the left auricle and right 
ventricle in mitral stenosis. Hypertrophy is usually inversely pro- 
portional to the dilatation. In combined valvular lesions, as aortic and 
mitral insufficiency, the heart is enormous — the ox heart, cor bovinum, 
bucardia. (b) Causes raising arterial blood pressure, as stenosis of the 
aorta, arteriosclerosis, and nephritis. These causes produce hyper- 
trophy and dilatation of the left ventricle. Workers in caissons may 
suffer from dilatation, (c) Causes raising blood tension in the lesser 
circulation, as spinal deformity, chronic disease of the lungs and pleura, 
which produce hypertrophy of the right ventricle ; of these emphysema 
is the most important. Abdominal lesions are thought by French 
writers to reflexly raise the pulmonary blood pressure and induce 
hypertrophy and dilatation. Lichtheim's classic on the lesser circula- 
tion proved that the lung vascular area must be reduced more than 25 
per cent, in order to affect the right heart. The size of the heart varies 
much physiologically; rapid heart action allows less complete physio- 
logical dilatation than does slow action. When there is pulmonary 
obstruction with its consequent heart changes, the patient stands 



DILATATION OF THE HEART 435 

pneumonia, bronchitis, and other infections very poorly. When severe 
exercise is indulged in, the systole is incomplete and right-heart dilata- 
tion — even tricuspid regurgitation and marked venous stasis — may 
follow. Air embolism also produces dilatation. Physical training 
increases the power and reserve strength of the right heart; i.e., it 
increases the "wind" and endurance. An equal effort in an individual 
out of training, or in a man with poor nutrition, " breaks his wind" and 
produces transient or permanent cardiac exhaustion. 

2. Nutritive Disturbances. — Dilatation may be induced (a) by acute 
infections, leading to cardiac degeneration or acute myocarditis; (b) 
by anaemia, hemorrhages or loss of fluids; (c) by chronic myocarditis, 
fatty heart, or coronary atheroma, possibly following sudden heart 
strain as in athletics; by endo- or pericarditis invading the heart muscle 
by contiguity, pericardial adhesions, etc.; (d) by poisons, alcohol, 
tobacco, chloroform or anaesthesia; (e) it very frequently follows hyper- 
trophy or is associated with it. 

Symptoms. — The symptoms are those of cardiac insufficiency 
(v. Uncompensated Valvular Disease), as dyspnoea — which is es- 
pecially great in pericardial adhesions — cardiac asthma, cough, syncopal 
attacks, and precordial anxiety. Cardiac failure begins when the sys- 
tole is unable to expel all the blood from the dilated chambers. 

Physical Signs. — It is not easy to separate the signs of hypertrophy 
and those of dilatation. 

1. Dilatation of the Left Ventricle. — (a) On inspection, the apex beat 
is dislocated downward and to the left and is diffuse, undulating and 
weak, if indeed it is not absent, (b) On palpation, the apex may not 
be felt even though visible (Walshe). In other cases the apex and heart 
shock are snappy and may feel strong to the inexperienced hand; the 
sharp, snappy action contrasts sharply with the weak, rapid, and 
often irregular radial pulse, (c) On auscultation, the heart tones are 
weak, though sometimes snappy. The first apex tone is more valvular. 
The second aortic sound is weak because of poor arterial tension. In 
insufficient hearts, the heart tones sound alike, a condition termed 
embryocardia from its resemblance to the foetal heart tones. An apical 
systolic murmur is frequent, especially in arteriosclerotic dilatation. 
It is sometimes due to relative insufficiency of the mitral valve whose 
normal circumference of three and one-half inches may be increased by 
one or two inches. Von Jiirgensen holds that it is often due to irregular 
muscular contraction. Rest and the administration of digitalis fre- 
quently cause it to disappear. Gallop-rhythm, in which three tones are 
heard, like the rhythm of a galloping horse, consists of either doubling 
of the first (Potain) or second tone (Fraentzel), or of the addition of a 
presystolic tone (Rosenbach) caused by the auricular contraction. It 
is heard in the failing hypertrophied hearts of nephritics more than in 
all other conditions combined. It is also found in valvular lesions, 
atheroma, emphysema, and in acute diseases such as pneumonia, 
typhoid, and diphtheria. The auricle (causing the extra sound) 
cannot long compensate. Whatever its cause, it is a sign of great danger 



436 DISEASES OF THE CIRCULATION 

although the heart's tone may temporarily improve with rest and with 
the use of heart tonics, (d) On percussion, the heart extends to the left 
and downward, giving a more oval area of dulness. 

2. Dilatation of the Right Ventricle. — This is more common, (a) 
On inspection, a diffuse beat is seen to the right of the sternum or 
indeed in the epigastrium; and (6) it may be palpated, (c) Ausculta- 
tion shows weakness of the heart tones, and (d) percussion outlines 
dulness *to the right of the sternum. Extreme dilatation increases the 
tricuspid orifice from four and one-half to five or six and one-half 
inches, and the physical findings of (relative) tricuspid insufficiency 
obtain. 

3. Dilatation of the Auricles. — The deep location of the left auricle 
renders it almost impossible to obtain physical signs of dilatation. 
The changes usually ascribed to the left auricle are due to enlargement 
of the conus of the right ventricle, though a presystolic wave may be 
seen in the second left interspace. The right auricle is frequently 
distended and this is recognized by undulation to the right of the ster- 
num above the right ventricle, by dulness, and sometimes by a presys- 
tolic wave. 

Dilatation of all the chambers, both right and left, combines the 
physical findings of each type, thus giving the heart a triangular or a 
trapezoid conformation. The cardiac symptoms and physical findings 
of dilatation may develop gradually, or abruptly after violent exercise, 
especially when the heart is congenitally weak or when its nutrition is 
altered. 

Diagnosis. — The diagnosis depends on the etiological factors, the 
weak tones, the increased dulness, and cardiac and somatic evidences 
of cardiac failure. The greater the dilatation, the less marked is the 
difference between the systole and diastole. The absolute heart dulness 
in middle life is bounded by the left border of the sternum, the fourth 
or fifth rib, and the left parasternal line, or it may extend even a 
little more to the left. The relative dulness reaches from the third or 
fourth rib above to the apex beat on the left and to a line drawn ob- 
liquely from the third left costal cartilage across the sternum to the fifth 
right costal articulation. Percussion is difficult in distorted, fatty or 
cedematous chests. Differentiation concerns the same group of con- 
ditions discussed under the diagnosis of effusive pericarditis (q. v.). 
The Schott method of treatment (v. i.) frequently is of value in diag- 
nosis; it helps dilatation but is without effect on pericardial exudate. 
Rest and the use of digitalis greatly benefit dilatation and hydroperi- 
cardium, sometimes within a very short time, while pericardial 
effusion is unaffected by this treatment. Consolidation of the adjacent 
lung margin can usually be recognized by the altered breathing and 
rales. Mediastinal tumor and aneurysm are suggested by pressure 
symptoms. If the margins of the lung are adherent from pleural adhe- 
sions, especial care in percussion is imperative, and dilatation is diag- 
nosticated by the relative, more than by the absolute, heart dulness. 
Palpatory percussion, very lightly made, is most valuable and the feel 



DILATATION OF THE HEART 437 

of the increased dulness has greater diagnostic value than the sound 
elicited. Emphysema may greatly obscure the outlines of the heart, 
but the heart's outlines are usually disclosed by careful palpatory per- 
cussion for the relative dulness. Encapsulated pleurisy is differentiated 
by careful puncture, if other signs fail. The fluoroscope is frequently 
of aid. In short chests, the apex is seen normally at or even beyond the 
nipple. This occurs in 12 per cent, of women. Though spinal curva- 
ture frequently overtaxes the right heart and thus induces dilatation, 
the diagnosis must be made with care, for the topographical relations 
are much disturbed by visceral luxation, and the irregularity of the 
sternum and ribs makes percussion uncertain. In fat individuals, 
dulness may result from adipose deposit in the mediastinum, but dif- 
ferentiation is often easy by means of the normal, though perhaps 
distant, heart tones and by the character of the pulse. Dilatation must 
not be mistaken for dislocation due to gaseous, tumor, or fluid disten- 
tion of the abdomen. 

Prognosis. — The prognosis depends on the individual and on the 
etiology. 

Treatment. — The therapy is as follows: (a) The cause must be 
treated, (b) The dietetic, special and general indications of valvular 
disease (q. v.) must be carried out. (c) OerteVs treatment consists of (i) 
limitation of the amount of water ingested, and stimulation of its excre- 
tion by sweats and deep inspirations. Beer must be interdicted, but 
many nervous subjects tolerate limitation of water very poorly. Water 
should be given in small quantities at frequent intervals, (ii) Re- 
duction of the body-weight (see Obesity), (iii) Stimulation of the 
circulation by exercise. Mountain climbing is said to stimulate the 
heart, develop the respiratory muscles, increase the lung capacity, and 
widen the vessels. The objections to active exercise are that rest in 
bed gives better results, and that exercise causes harm when the heart 
muscle or coronaries are diseased, or when endocarditis, pericardial 
adhesions, or B right's disease exist, (d) The so-called Schott method 
was originated by Beneke and Saetherburg, and was elaborated by the 
Nauheim physicians. It consists of (i) baths in springs containing 
sodium and calcium chloride, iron carbonate, and carbon dioxide. 
The temperature should be a few degrees below body-heat, and a little 
carbon dioxide should be used in the baths at first. They should be 
given once daily for two or three days, and then intermitted; they 
should last from five to twenty minutes. They may be given artificially 
with almost equally good results, using 40 gallons of water, with 3 
to 10 pints of salt, 10 ounces of pure calcium chloride and carbon 
dioxide generated in a vessel from sodium bicarbonate and hydrochloric 
acid. The temperature should be later reduced to 90° or less, and the 
amount of carbon dioxide should be increased. The bloodvessels are 
first contracted and later dilated. The pulse becomes slower and fuller, 
dilatation decreases, stasis is lessened, diuresis is increased, and the 
metabolism of the muscles and heart is improved, (ii) Resisted move- 
ments should be carefully and gradually employed. Though active 



438 DISEASES OF THE CIRCULATION 

exercise constricts the vessels, gentle movements by the patient, resisted 
by the operator, dilate the vessels. 

Yeo (Manual of Medical Treatment) summarizes the resistance 
movements as follows: 

Each exercise is made against slight resistance applied by the physician or a trained 
assistant. 

1. The arms are extended in front of the body at the level of the shoulder, with the 
palms of the hands touching. The two arms are then moved slowly outward till they 
are in a line with each other; they are then brought back to their original position. 

2. The arm and hand hanging down with the palm turned forward, the forearm is 
flexed upon the arm (which is kept still) until the fingers touch the shoulder. The 
forearm is then extended to its original position. This is first done with one arm and 
then with the other. 

3. The arms, hanging down as in No. 2, are raised outward until the thumbs meet 
over the head; they are then returned to their original position. 

4. With arms dependent, the fingers, at the first phalangeal joints, are pressed 
together, and the arms are then raised until the hands are above the head, after 
which they are brought back to their original position. 

5. The arms, hanging in the position of "attention," are advanced forward parallel 
to each other until they are elevated to a vertical position; they are then brought 
back to where they were before. 

6. Same as No. 1, but with fists clenched. 

7. Same as No. 2, but with fists firmly clenched. 

8. The arms, starting from the position of "attention," describe a circle by moving 
forward and upward until they are raised vertically; then each palm is turned out- 
ward, and the arms descend backward to their former position. 

9. The body is bent forward, and then brought back to the erect position, the 
knees not being moved. 

10. The body is rotated, without any movement of the feet, first to the right and 
then to the left, and then back to its original position. 

11. The body is flexed laterally, as far as possible, first to the one side and then to 
the other, and afterward restored to its original erect position. 

12. The patient, standing with the feet side by side and supporting himself by 
leaning with one hand upon any object, flexes the opposite thigh as far as it is possible, 
and afterward extends it until the feet are again side by side; then, leaning on the 
other hand, he carries out a similar movement with the other thigh. 

13. The patient, supporting himself by one hand, as in 12, and the knee being kept 
straight, each leg in turn is raised as high as possible in front of the body, and then in 
the same way behind. 

14. Supporting himself by placing both hands in front on the back of a chair, the 
patient first flexes one leg and then the other upon the thigh as far as he can. 

15. Each leg in turn is abducted as far as possible, the knees being kept straight, 
the patient resting on one or other hand the while. 

16. The arms, held horizontally outward, are rotated forward and backward at 
the shoulder joint. 

17 and 18. Flexion and extension, first of the wrists, and second of the ankles. 

In resisting these movements the operator places the palm of his hand on that side 
of the patient's limb or body toward which the movement is to be made. In the 
movements of the wrist the operator closes his thumb and forefinger round that joint. 

(iii) Passive movements and massage. Contraindications to Schott's 
method are aneurysm, angina pectoris, acute cardiac insufficiency, 
tendency to hemorrhage and embolism, and possibly nervousness. 



HYPERTROPHY OF THE HEART. 

Pathology. — The muscle fibers increase even tenfold in size (hyper- 
trophy) and increase in number (hyperplasia). Hypertrophy may exist 
alone — simple hypertrophy. It more frequently occurs with dilatation 



HYPERTROPHY OF THE HEART 439 

— eccentric hypertrophy. Concentric hypertrophy, i. e., with decrease in 
the size of the ventricle, is rarer and some regard it as merely a post- 
mortem condition; the ventricle may be firmly contracted in death 
from violence or from cholera, or hemorrhage, but it can be distended 
by the finger. The size of the normal heart is that of the fist (Laennec), 
and the normal weight is about 9J ounces (300 gm.). The heart is 
sometimes increased four times in weight, even to 59 ounces (1,980 
gm.) (Stokes) — the cor bovinum. Its consistence is increased, and its 
color is normal or darker. In total hypertrophy the heart is round; 
in partial, the right or left ventricle is larger. The left ventricle 
normally measures nine to ten millimeters, but this may be more than 
doubled in hypertrophy; the right ventricle measures three or four 
millimeters; the left auricle measures three, and the right two, milli- 
meters. In the foetus the ventricles are equally thick. Up to the 
eighth year, the left ventricle is relatively thicker than in the adult, 
because of narrowing of the aorta at its isthmus. 

Etiology. — The causes of hypertrophy of the left ventricle are usually 
mechanical resulting from (a) valvular lesions (aortic stenosis and 
insufficiency, mitral insufficiency) ; (b) renal disease; usually from a 
chronic interstitial nephritis but occasionally from other forms, from 
hypoplasia of one kidney, from hydronephrosis, etc. It is caused by 
mechanical obstruction to the flow of blood or by retention within the 
blood of waste substances which excite arterial spasm; (c) arterio- 
sclerosis (q.v.), developed by Traube; (d) congenital narrowness 
(hypoplasia) of the arterial system, or of the aorta at the isthmus; (e) 
dilatation of the aorta, diffuse or aneurysmatic, or occurring rarely from 
general arterial dilatation (Nothnagel and Fraentzel); (/) pericardial 
adhesions; (g) myocarditis (q.v.); (h) pregnancy; it is claimed that 
the placental circulation or increased intraabdominal pressure in- 
creases the heart's work. The high diaphragm apposes the heart to the 
chest wall and tips the apex outward so as to simulate hypertrophy; 
(i) over-exertion; the " irritable heart of soldiers" (Da Costa, Myers, 
Fraentzel) is caused by forced marches, cold, and mental excitement; 
the so-called idiopathic hypertrophy occurs in hard workers, and 
especially in Munich from excessive use of beer and from the resulting 
plethora; hypertrophy results from continued hard work while 
dilatation follows sudden cardiac strain; (j) nervous causes; these 
are exophthalmic goitre, and the use of tobacco, especially strong 
Havana cigars, which causes rapid irregular heart action. Pujatin, Ott 
and others have found degenerative and sclerotic changes in the 
cardiac ganglia. 

Hypertrophy of the right ventricle depends on (a) hypertrophy con- 
secutive to left heart disease; the entire heart usually hypertrophies 
from the intimate connection between the muscular fibres of both sides ; 
(b) right-heart valvular lesions and congenital heart disease; (c) in- 
creased pulmonary pressure from disease of the pulmonary artery, or 
pressure upon it; (d) emphysema, chronic bronchitis , spinal deformity, 
pulmonary induration, bronchiectasis, and extensive pleural adhesions. 



440 DISEASES OF THE CIRCULATION 

Hypertrophy of the auricles always coexists with dilatation (stenosis 
of the auriculo ventricular orifices). 

Symptoms. — Hypertrophy of the left heart may exist without any 
subjective sensations, or there may be palpitation, inability to lie on the 
left side, cough, cardiac oppression or pain or cerebral congestion 
(tinnitus, flashes before the eyes, headache, or vertigo). There is 
frequently a tendency to hemorrhage (epistaxis, cerebral hemorrhage, 
excessive menstruation). Polyuria results from high arterial tension. 
The causal disease (nephritis, valvular disease, arteriosclerosis, 
emphysema) presents its own symptoms. Right-heart hypertrophy is 
attended by brown induration of the lungs, haemoptysis, cyanosis, or 
bronchial catarrh. 

Physical Signs. — Much confusion in the clinical description prevails 
because the signs of hypertrophy are very often confounded with those 
of dilatation, although both conditions very frequently coexist. 

Hypertrophy of the Left Ventricle. — 1. Inspection. — This discloses 

(a) a strong, sometimes heaving, diffuse apex; essential dislocation 
to the left or downward indicates coincident dilatation, because 
thickening of the heart muscle alone scarcely gives any increase in 
the size of the heart. Rotatory retraction of the apex beat is sometimes 
seen, (b) Precordial prominence; (c) forcible pulsation of the vessels. 

2. Palpation. — Palpation confirms (a) the strong apex beat, detects 

(b) the palpable second aortic tone due to high tension (or atheroma), 
and sometimes (c) a systolic apical thrill (transmission of the strong first 
tone), (d) The pulse is regular, full and hard in simple hypertrophy, 
but in the eccentric form it is softer and more rapid. It is sometimes 
weak or almost absent in the arms; this is due to loss of vessel tonus. 
(e) Thrills over the peripheral vessels from high tension vibration may 
be felt. 

3. Percussion. — It is usually stated that the left heart is dislocated 
downward to the left but this is infrequent, as enlargement means 
dilatation (or an atheromatous relaxed aorta which allows sinking of the 
heart) . 

4. Auscultation. — This brings out (a) usually the loud first tone, over 
the apex (but not always, as for example in aortic leakage) ; it discloses 
(6) the accentuated and frequently metallic second aortic tone; (c) systolic 
arterial bruits from tension and vibration of the walls; (d) the gallop- 
rhythm in cases of failing hypertrophy, especially in nephritics; (e) a 
peculiar clink, which is sometimes heard to the right of the apex; (/) 
an apical systolic murmur is sometimes heard, and is frequently 
of the cardiopulmonary type. Seitz, Gendrin and others have re- 
corded murmurs resembling the pericardial rub, due to the violent 
beating of the heart or to muscular contraction (Jurgensen). 

Hypertrophy of the Right Ventricle. — (1) Inspection shows a strong, 
systolic impulse under the sternum which is (2) palpable, as is the strong 
second pulmonic tone. (3) Auscultation brings out the accentuated 
second pulmonic; and (4) percussion is negative, unless there is coinci- 
dent dilatation. 



ATROPHY OF THE HEART 441 

Diagnosis. — In left-sided hypertrophy, the cardinal signs are (a) the 
tense pulse, (6) the strong, hard apex beat, and (c) the accentuated 
second aortic tone; in right-sided hypertrophy they are (1) the strong 
second pulmonic tone, and (2) the substernal pulsation. Percussion is 
useless, for it discloses dilatation only. 

Hypertrophy of the left heart must not be confused with nervous 
overaction of the heart in which the apex is not heaving. Retraction of 
the left lung merely exposes more of the left ventricle, but the heart in 
this case seems enlarged upward and to the left. In narrow chests with 
poor lungs, the heart's dulness is wide, but the cardinal symptoms of 
hypertrophy are lacking. The same caution in the diagnosis of 
hypertrophy at puberty is necessary because at this period the heart is 
nervously unstable, the chest is thin, and the heart is normally wider 
than in the adult. Perplexity, may be caused when abundant casts and 
blood are found in the urine; these are usually indicative of nephritis, 
but, if there are other evidences of stasis, such as congested liver, they 
are compatible, in the minds of some writers, with stasis alone. Ne- 
phritis may cause hypertrophy; nephritis and hypertrophy may be 
due to a common cause; or a failing heart may produce renal stasis 
(see Nephritis, Differential Table). 

Prognosis. — The immediate outlook is good because hypertrophy is 
usually a compensatory process; the ultimate outlook is bad, because 
cardiac insufficiency is the ultimate issue. Symptoms usually appear 
first either gradually or suddenly in the stage of broken compensation 
from intercurrent fevers, malnutrition, or mental and physical strain. 
The best outlook is in hypertrophy caused by tobacco or athletics, for 
this may regress. Gallop-rhythm is ominous as is the occurrence of the 
first and second apical tones close together. Hypertrophy leads to 
fatty and other change in the heart, to sclerosis of the vessels, and in the 
pulmonary circuit to pulmonary atheroma, acute congestion, and 
oedema. 

Treatment. — The therapy is eminently causal and dietetic; alcohol, 
tea and coffee, tobacco, and cold baths, are to be avoided, and con- 
stipation must be prevented. The symptomatic treatment and the use 
of cardiants in the uncompensated stage are identical with the indica- 
tions in valvular disease. 



(C). ATROPHY OF THE HEART. 

Atrophy of the heart presents more pathological than clinical interest. 

Etiology. — The heart is at times congenitally weak and small. It 
may then be associated with small vessels, chlorosis (Virchow), or with 
hypoplasia of the genitalia (Rokitansky). Pressure atrophy, coronary 
sclerosis, pericarditic adhesions, the senile involution, and cachectic 
diseases, are the most frequent causes. Anatomically, the heart is 
reduced in size and weight (even to 1J ounces) the subpericardial fat 
disappears, the pericardium wrinkles, the coronary arteries are tortuous, 



442 DISEASES OF THE CIRCULATION 

and the heart muscle is pigmented. The valves, especially the aortic, 
may waste. The atrophy may be partial, as that of the left ventricle in 
some cases of mitral stenosis. Simple, concentric, and eccentric atrophy 
are described. 

The symptoms are indeterminate, and the diagnosis impossible. 

FATTY HEART. 

Etiology and Pathology. — Fatty heart is no distinct pathological nor 
clinical entity. Two forms are recognized, (1) fatty infiltration, and 
(2) fatty degeneration. 

1. Fatty Infiltration (Lipoma cordis capsulare, Virchow). — This 
form consists of invasion of the heart muscle by the subpericardial 
fat, which is normally found about the heart, in its furrows, at the tips 
of the ventricles, and around the basal vessels. The fat extends in paral- 
lel lines between the muscle fibers, which it may wholly replace. The 
fatty infiltration was considered primary by von Leyden; Struempell 
believes muscle atrophy is primary and the fatty infiltration secondary ; 
Rosenbach holds that fatty infiltration and muscular atrophy are 
secondary to a common nutritive disturbance. The fat, which is 
usually most developed in the outer layers of the myocardium, may 
reach to the endocardium. Fatty infiltration is most common in obese 
males over forty years of age, but has been seen in young subjects. 
It may occur after the menopause or in sterile women. Plethora, 
high living, excessive use of alcohol, and heredity, are factors. The 
heart is reduced 25 per cent, in weight compared with the body-weight 
(Hirsch). 

2. Fatty Degeneration. — This form is caused by deficient oxygena- 
tion which is either (a) general, resulting from acute infections, old 
age, cachexia, marasmus, anaemia, from such poisons as phosphorus, 
chloroform, or mercury, and from loss of fluids from diarrhoea; or 
(6) local or cardiac, from pericarditis; from coronary disease, which 
more frequently produces myofibrosis ; and from cardiac failure follow- 
ing hypertrophy. Most degeneration occurs in the left heart. The 
fatty heart is large and flabby; it is yellow-brown — the " faded leaf" 
color of Laennec ; the splashes and streaks of fatty degeneration con- 
trast with the normal areas, giving the variegated "tiger" or "tabby- 
cat" appearance; oil globules are found in rows in the muscle fibers 
and may replace them in part or in whole. Frequently the muscle 
fibers appear dry and granular ("albuminoid" degeneration) and this 
is probably the first step in fatty degeneration. The striations of the 
muscle disappear later. Its consistence is decreased and its muscula- 
ture is friable. 

The extent of the process is in direct ratio to the intensity of nutri- 
tive alteration; parenchymatous and fatty degeneration are observed 
in those segments of the heart where the greatest work and the most 
nutrition are demanded, as in the papillary muscles of the mitral 



FATTY HEART 443 

valves, and where pressure is greatest, viz., the interventricular 
septum and the left conus arteriosus. In embryonal life, these condi- 
tions obtain in the right heart. The early investigations of von Ley- 
den and those of more recent date by Goebel have determined that 
these changes are first focal and later diffuse. 

Symptoms and Signs. — No symptoms are characteristic. Extensive 
fatty changes may occur without clinical symptoms (latency), as in 
pernicious anaemia. Leube details a case without symptoms in which 
the apex was completely fatty. In some obese subjects, cardiac 
embarrassment develops with dyspnoea, palpitation, a somewhat 
characteristic wheezing, etc. The autopsy may reveal fatty heart, 
but far more frequently myocarditis, idiopathic hypertrophy, or cor- 
onary disease is found; i. e., there is no uniformity in the pathological 
findings, nor parallelism between them and the clinical signs. Though 
percussion of obese individuals is unsatisfactory, the heart is found 
dilated. In fatty heart, the tones are weak and distant, though pure, 
the apex beat is weak, diffuse, or absent, and sometimes an apical 
systolic murmur is heard, which is probably due to irregular systolic 
vibration. Gallop-rhythm is heard when the heart is fatigued. The 
pulse may be rapid from brain anaemia; it may be somewhat dicrotic, 
small, and arrhythmic. Low temperature, sweating, and bronchitis are 
common. 

Much stress was formerly laid on the Adams-Stokes syndrome, a 
triad of symptoms including (a) a slow pulse, even 14 to the minute, 
due to anaemic stimulation of the vasomotor centre, or to heart changes, 
and followed by (b) pseudo-apoplectic seizures, unconsciousness, tem- 
porary paralysis, or convulsions (pseudo-epilepsy), which are clearly 
dependent on cerebral anaemia, for one of Stokes's cases warded off 
these attacks by assuming the genupectoral position ; and (c) Cheyne- 
Stokes' respiration, in which respiration becomes slower, and is 
followed by a period of apncea lasting a half minute or more, with res- 
piration gradually returning to the normal. Narcotics increase or 
induce the condition. The pupils narrow during the apnceic period 
and muscular twitching is common. This triad is observed in uraemia, 
cholaemia, and diseases of the vagus and medulla as well as in heart 
disease. It seems likely that in Stokes' case the brain was also dis- 
eased. The syndrome is based on the bradycardia which appears to 
be most frequent in disease of the bundle of His (see Bradycardia, 
Cardiac Neuroses). 

Diagnosis. — The diagnosis is at best uncertain. As stated, fatty 
heart may cause no clinical symptoms, or the symptoms observed in 
the obese may be due to other lesions. Apparently increased dulness 
is often due to mediastinal obesity. The main point is to exclude 
valvular lesion and confine the diagnosis to a myocardial affection 
(v. Myocarditis). 

Prognosis. — The prognosis depends upon the cause. It is grave 
in diabetic or arteriosclerotic subjects, or when coronary disease, 
angina, lung oedema, or an irregular or very slow pulse intervene. 



444 DISEASES OF THE CIRCULATION 

Sudden death is not uncommon from acute dilatation, pulmonary em- 
bolism, brain anaemia or hemorrhage, " heart block" (described under 
bradycardia), or rarely from heart rupture. 

Treatment. — The treatment is that of obesity in fatty infiltration, 
but distinction must be made between (a) obesity with anosmia, in 
which the subject is obese and pale, with cold extremities, much 
sweating, scanty urine, weak and easily fatigued muscles, and dyspnoea; 
and (b) obesity with plethora, in which the color is red, the urine in- 
creased and uratic, the heart stronger, the muscles fairly developed, 
and exercise possible with little dyspnoea. Schott's treatment is bene- 
ficial in the first type, and Oertel's method in the latter (see Dilatation 
of Heart). Saline cathartics, total abstinence from alcohol, and the 
use of potassium iodide for general or coronary sclerosis are indicated. 
The brain symptoms of anaemia and the sudden syncope are met by 
the aetherial alcoholics. Cardiac insufficiency is treated as in uncom- 
pensated valvular lesions and dilatation. Morphine should be avoided 
entirely or used only with great circumspection. 



ACUTE MYOCARDITIS. 

Etiology and Pathology.— Acute myocarditis is of the greatest 
clinical and prognostic importance. 

Acute diffuse parenchymatous myocarditis corresponds to granular 
and fatty degeneration (v. L); to the "mushroom" heart of Stokes 
(described under Typhus) which, when held inverted by the base, 
would fall like a cap over the hand; and also corresponds to the " soft- 
ened heart" of Laennec and Louis. 

Acute diffuse interstitial myocarditis has been most studied of late 
years, while formerly the degenerations attracted most attention. 
Round cells are found in the interstitial tissue, with or without muscular 
alteration. Vacuolization, nuclear multiplication, pigmentary deposit, 
blood extravasations, waxy and other changes are also found. Though 
it was first discovered by Leyden in scarlatina, it is found in a very 
large percentage of cases of diphtheria and typhoid by Rhomberg; 
it also occurs in acute endocarditis and rheumatism (10 to 20 per 
cent.), less frequently in variola, influenza, gonorrhoea, quinsy, and 
other infections. Though the typhoid bacillus, the gonococcus, and 
Bacillus pyocyaneus have been found in the myocardium, they are 
chiefly important as causing toxaemia. In some instances acute myo- 
carditis is seemingly primary. 

H. Martin has found inflammatory thickening of the intima in the 
coronary radicles, also minute thrombi, lamellar splitting of the elastic 
tunic, and proliferation of the media. Rhomberg found a perineuritis 
in one-half of typhoid and diphtheria autopsies. Virchow, Hayem, 
and Renault, hold that inflammation is primary and degeneration 
secondary; Weber, Blind, and others regard the process as degenera- 
tion rather than inflammation. 



ACUTE MYOCARDITIS 445 

Symptoms and Signs. — During the progress of an acute infection, 
the heart's strength decreases; its tones, especially the first mitral, 
become fainter; the apex is less distinct and is dislocated somewhat 
to the left by dilatation ; and the pulse grows weaker and more irreg- 
ular. Vasomotor relaxation is probably a very important element in 
the heart failure. Gallop-rhythm and embryocardia develop, and there 
is usually a relative (muscular) mitral leakage. Cardiac pain may be 
severe. These changes may develop during the infection as is the 
case in typhoid, scarlatina, and rheumatism; or they may occur sev- 
eral (two to ten) weeks after the infection, as in 10 to 20 per cent, of 
the cases of diphtheria. Sudden death without symptoms may occur 
during convalescence. Rheumatic myocarditis often leads to chronic 
fibrous myocarditis. 

Diagnosis. — The diagnosis is made from the etiology; acute myo- 
carditis is distinguished with great difficulty from acute endocarditis 

Treatment. — 1. Prophylaxis. — Hydrotherapy is indicated in typhoid 
and antitoxin in diphtheria; the patient should have absolute rest 
well into convalescence, because sudden heart insufficiency, or unex- 
pected death may follow effort, difficult defecation, or other exertions ; 
sexual intercourse should be forbidden. The heart must be carefully 
watched in every convalescence. 

2. Cardiants. — These are indicated as in valvular incompetency, 
although digitalis and strychnine are apparently of little use. 



Acute Oircumscript Myocarditis. 

Acute circumscript myocarditis (the disease of gladiators, Galen) 
is usually septic and embolic. It is one form of sepsis, and its heart 
foci are usually multiple. It is usually caused by the pyogenic organ- 
isms. The issues are (a) resorption with fibrosis, (b) caseation or 
calcification, and (c) rupture into the pericardium or into the heart 
cavity, thus producing "heart ulcers" and pulmonary or arterial 
embolism, heart aneurysm, abnormal communications between the 
chambers, or sudden valvular insufficiency. The latter is sometimes 
suggestive, though it is usually impossible to make a diagnosis. The 
treatment is that of the fundamental septicopyemia and the resulting 
cardiac insufficiency. 



Fragmentation of the Heart Muscle. 

Fragmentation of the heart muscle (Zenker, Virchow, Rindfleisch, 
Coats, Renault, and Landouzy) occurs in two forms (a) segmentation, 
or separation from each other of the heart fibers, and (b) fragmenta- 
tion, or rupture across the normal or degenerated muscle fibers. It 
has also been called segmentary myocarditis, and though it most 



446 DISEASES OF THE CIRCULATION 

frequently occurs in death from violence, it may have some clinical 
significance in cases of sudden or gradual heart weakness (see 
Myolysis under Diphtheria). 



CHRONIC MYOCARDITIS (CHRONIC FIBROUS OR INTERSTITIAL 
MYOCARDITIS, MYOFIBROSIS CORDIS). 

Etiology and Pathology. — Chronic myocarditis is rarely a disease 
sui generis, and the term is somewhat ill-chosen. It is a sequel of 
some previous retrogressive lesion — a secondary process. It compen- 
sates for destruction of heart tissue, and is in itself a measure of 
that loss. It is more often a fibroid degeneration than an inflammation. 
The longitudinal incision of the heart muscle discloses the scar-like 
tissue which is often unseen in the ordinary transverse sections (Koester 
and Ruhle). This tissue is seen most frequently in the left ventricle 
(lower two-thirds of its anterior wall near the apex and the upper 
two-thirds of its posterior wall near the auricle) as glistening sunken 
areas under the pericardium or endocardium. It also occurs in 
the papillary muscles or interventricular septum. The scars appear 
as streaks, flecks, stellate plaques, sometimes measuring three or four 
centimeters, or even larger. The foci may be macro- or microscopic, 
circumscribed or general. Large areas may form from fusion of small 
foci. Gross changes in the heart include the following: 

1. Hypertrophy. — This is vicarious and occurs when the fibrosis is 
not great. The relation is twofold; (a) hypertrophy often compen- 
sates for muscular destruction and maintains the heart; or (6) fibrosis 
develops in tired hypertrophied hearts. Hypertrophy is inversely 
proportional to the number of scars. 

2. Dilatation. — This follows extensive fibrosis and decreased power 
to resist pressure. Fibrosis of the tissue can neutralize dilatation to 
some extent, and is therefore a conservative agent. 

3. Atrophy of the Myocardium. 

4. Valvular Disease. — This has no necessary affiliation with myo- 
carditis, though they are indirectly associated. A relative mitral 
insufficiency may follow myocarditis in the mitral papillary muscles 
(Hamernjk). Dittrich first described the genuine heart-stenosis, a 
cicatricial contraction of the left conus arteriosus in the adult, or of 
the right conus in the foetus, following myocarditis at those sites. 
Relative aortic insufficiency may follow enormous dilatation and myo- 
carditis of the left ventricle (personal observation). 

5. Partial Heart Aneurysm and Heart Rupture. — Partial heart 
aneurysm, a localized bulging of the heart wall, is seen largely near 
the apex (left ventricle, 68 per cent, of cases, Pelvet), where acute 
myomalacia cordis or chronic fibrosis occurs most frequently; it is 
seen more rarely at the base, or in the interventricular septum which 
may bulge into the right heart; and it occurs most infrequently in 
the right ventricle or auricle. The heart aneurysm is usually small, but 



CHRONIC MYOCARDITIS 447 

may equal the size of the heart ; it is usually single (though four were 
found by Thurnam), and may communicate with the heart cavity 
by a neck-like constriction; its walls consist of connective tissue 
which is rarely ossified as in Corvisart's case; it often contains thrombi 
and is adherent to the pericardium. In unfavorable cases it ruptures 
or tears loose a valvular attachment. During twenty years ending in 
1903, D. G. Hall found 112 cases recorded (26 had aneurysm in the 
valves, and 25 in the coronary vessels) ; Voelker alone made a diagnosis. 
Rupture of the heart occurs through the left ventricle (80 per cent.). 
Pathogenesis. — The most frequent cause is disease of the coronary 
arteries, which are incessantly active and are end-arteries, anastomos- 
ing with each other only through their capillaries. The vessels of 
Thebesius, entering the muscle from the auricles and ventricles as 
well as some supernumerary vessels, may carry on a collateral circula- 
tion when the coronary arteries are occluded. Coronary narrowing 
may be gradual, by slow obliterative endarteritis in the trunk or by 
the occlusion of the vessel from an atheromatous plaque in the aorta; 
or it may be sudden and fatal by embolism or thrombosis in an already 
narrowed vessel. The most common location for coronary obstruction 
is in the left ventricle (anterior coronary artery which is most active, 
and relatively small) and in the interventricular septum. In fairly 
acute coronary obstruction, the heart muscle becomes ischemic, pale 
yellow or white, and opaque; and the necrotic area becomes swollen 
and prominent (coagulation necrosis). A wedge-shaped anaemic (or 
hemorrhagic) infarct is less common than an irregularly outlined 
necrosis. The muscle fibers become fragmented, lose their nuclei, 
and disappear; this process may lead to rupture of the heart. Ziegler 
named it myomalacia cordis. White cells surround the focus. Sudden 
death is very common. If the subject lives, scar-tissue develops to 
replace the deficit, and is known as dystrophic sclerosis. Such "myo- 
carditis" is not inflammatory; it is often an uncomplicated coagula- 
tion necrosis with substitution by scar-tissue. Huchard employs the 
terms, arteriosclerosis of heart and arterial cardiopathy, to emphasize 
the causal role of arterial disease. Coronary arteritis most frequently 
runs a subacute or chronic course. Its causes are those of arterio- 
sclerosis (q.v.). A less frequent cause is actual chronic myocarditis 
following acute myocarditis due to acute infections, such as rheu- 
matism, typhoid, or diphtheria. Koester, Ruehle, and others have 
found myocarditis in cases of cardiac insufficiency, resulting from 
valvular disease, and also in idiopathic cardiac hypertrophy. French 
writers describe an acute endarteritis following acute infections and 
leading to myofibrosis. Dehio holds that myocarditis, or myofibrosis, 
is a result of dilatation, that it occurs where the muscle is destroyed, 
and is therefore a necessary and protective process. This view con- 
forms with Thoma's conception of arteriosclerosis (q.v.). Dehio 
considered that myofibrosis has no affiliation with acute myocarditis, 
that it occurs in all cavities of the heart, and often in the weaker 
and more dilated auricles, that dilatation is the determining factor, 



448 DISEASES OF THE CIRCULATION 

and that it is always a process secondary to the degeneration of hyper- 
plastic muscle, to pressure, and to venous stasis. 

Symptoms. — (a) In the latent type there are no symptoms, and 
sudden apoplectiform death occurs, while the subject is apparently 
in perfect health. (6) Most cases present chronic symptoms of cardiac 
insufficiency. The cervical veins are enlarged and there is general 
venous congestion. The pulmonary circulation suffers especially, as 
is shown by cyanosis, by duskiness of the skin, by infarcts which 
are often large (Ruhle), by hydrothorax, oedema of the lungs, bron- 
chitis, and by dyspnoea which is often nocturnal and develops on 
exertion. The heart symptoms are precordial oppression or dull pain, 
palpitation, cardiac asthma, or genuine angina pectoris. Examination 
of the heart sometimes gives negative results, but dilatation and 
hypertrophy are usually present (cardiomegalia). The heart tones 
at first are often clear, but later become faint and irregular, so that 
in the resulting delirium cordis, the tones are disorderly, and the phase 
of the murmur, due to relative muscular insufficiency or to arterio- 
sclerotic dilatation, cannot be distinguished. The second pulmonic 
sound is accentuated or split, and the second aortic tone is weak, 
because the arterial tension is low. The pulse is usually irregular 
(Ruhle, Riegel, Bard, Phillippe), and may be so either from the begin- 
ning or may become so later, with paroxysms of arrhythmia which 
some consider an extension of the degeneration and sclerosis. Irreg- 
ularity usually precedes the cardiac insufficiency and persists during 
restoration of compensation. A regular pulse may be present through- 
out (Ebstein and Renoy), or a number of regular strong beats is fol- 
lowed by a wave of rapid tumbling heart action. Simple intermission 
and the pulsus bigeminus are also seen. The pulse rate is often slow 
at first, and gradually increases to 90 or 100, with ominous crises of 
tachycardia. In some instances the pulse is persistently slow and this 
is associated with syncope from brain ansemia (v. i. Bradycardia). 
It is seen, then, that the rate and rhythm of the pulse vary, and though 
irregularity is of important diagnostic value there is no constancy in 
the pulse findings. 

(Edema is present, but as a rule is less common and intense than 
it is in valvular disease. Embolism may occur. Digestive disturbances 
are almost constant (Ruhle), and Huchard maintains that they have 
an important bearing on the heart's action; alimentary autotoxsemia 
from carelessness in regard to diet, may cause paroxysmal cardiac 
symptoms. Potain and Barie hold that digestive disorders induce a 
reflex contraction of the lung vessels and thus lead to dyspnoea. The 
urine is that of stasis in the later stages, but early in the disease poly- 
uria may prevail from hypertrophy and high blood pressure. Renal 
insufficiency may lead to renal toxaemia (Houchard). 

Diagnosis. — There Are Five Cardinal Points. — (a) In the majority of 
cases arteriosclerosis is most important. Its causes should be sought 
in the anamnesis, and the peripheral arteries and aorta should be 
examined for its usual signs (q. v.). Arteriosclerosis is usually general, 



CHRONIC MYOCARDITIS 449 

but may exist in the heart or brain without being seen in the radial 
arteries, and the converse is also true, (b) The heart is usually dilated 
and hypertrophied ; i. e., its transverse measurement is increased, (c) 
No valvular murmur exists (in uncomplicated cases). The systolic 
apical murmur of arteriosclerotic dilatation may be heard or the soft 
variable bruit of relative mitral leakage, which often disappears with 
rest and catharsis, (d) The pulse is fast and irregular. A regular 
pulse does not absolutely exclude myocarditis. Arrhythmia, whether 
congenital, neurasthenic, or caused by tobacco, must be excluded, (e) 
Dyspnwa and pulmonary stasis are suggestive. 

Differentiation is often so difficult that many able clinicians limit 
the diagnosis to muscular insufficiency; for fatty heart, idiopathic 
hypertrophy and dilatation, or pericardial adhesions, may be found at 
autopsy instead of the anticipated myocarditis. Sometimes when myo- 
carditis is suspected, the heart shows nothing microscopically or 
macroscopically, thus demonstrating that the causes of heart failure 
are often beyond the detection of the microscope. A diagnosis is 
made by exclusion, and then is often only a " probability diagnosis." 
In distinguishing myocarditis from the " heart of renal disease," long 
observation, the gallop-rhythm (more common in the cor renale), and 
ursemic manifestations are helpful. Myocarditis and renal disease are 
rather frequently associated. From mitral stenosis: both lesions cause 
irregularity and a weak, radial pulse and apex beat; when the pre- 
systolic stenotic murmur is absent, the loud second pulmonic sound, 
the loud, snapping, apical tone and the wide, right heart are most 
suggestive of mitral stenosis. Digitalis very frequently fails to act in 
myocarditis. From cerebral apoplexy: the sudden "stroke" or " car- 
diac apoplexy" of coronary disease may be the first sign of myocardial 
disease and may be mistaken for hemorrhage of the pancreas, cerebral 
apoplexy, or embolic processes. The autopsy, in cases of sudden 
death or death after a few hours, often discloses coronary closure with 
myomalacia cordis or fibrous myocarditis. 

Prognosis. — The prognosis is that of uncompensated valvular lesions 
with the extra consideration that the muscle itself and most often its 
nutrient arteries are involved. Because of the facts that digitalis is 
often inefficient in these cases, and that angina pectoris, cerebral 
anaemia, heart rupture, or coronary closure may occur, the outlook 
is most unpromising. Some patients, especially elderly subjects, may 
live a decade or more, until intercurrent pneumonia or another secon- 
dary affection causes their death. Early digestive symptoms are less 
favorable than early oedema or congested liver. 

Treatment. — The therapy is (a) that of the causal factor, arterio- 
sclerosis (q. v.) being the most common cause. Potassium iodide 
relieves pain, and lessens the atheroma; it should be given in doses 
of 5 to 10 grains after meals, freely diluted in milk or water — 

Potassii iodidi oiiss- 

Syr. sarsaparillse co §iv. 

M. et S. — One teaspoonful in a glass of water after meals. 



4.50 DISEASES OF THE CIRCULATION 

(b) Dietetic; stimulants should be used carefully, and overexertion 
and excitement should be avoided, (c) The Schott treatment (v. s.). 
(d) Cardiants. Digitalis is beneficial in the less developed, but not 
in the advanced cases. It is to be avoided when the pulse is slow. 
Strychnine is frequently valuable. When there are anginal seizures 
or hard vessels, nitroglycerine should be given (see Therapy of Val- 
vular Disease). Nitrite of amyl is usually ineffectual. Caffeine, 
camphor, morphine, and alcoholics should be administered for cardiac 
asthma; morphine is considered somewhat dangerous in angina pec- 
toris (q. v.). 

RUPTURE OF THE HEART. 

Etiology. — (a) Spontaneous rupture is practically unknown, (b) 
Rupture through the altered heart muscle occurs in myocarditis, heart 
aneurysm (in which case it may even perforate the chest wall), myoma- 
lacia cordis (from coronary atheroma and embolic occlusion), coronary 
aneurysm; fatty heart, abscess, gumma or neoplasm of the heart, 
ulcerative endocarditis or obstructive valvular disease, and stenosis 
of the isthmus of the aorta. It occurs largely in men over sixty years 
of age. It may occur during sleep or may be caused by trauma, vomit- 
ing, great effort, excitement, delivery, coitus, or by the use of digitalis. 
Kroll collected 332 cases of rupture of the heart. 

Pathology and Symptoms. — (a) Partial rupture of the valves in- 
duces sudden valvular insufficiency. (6) Total rupture of the heart is 
usually single (though a case having five rents is recorded), and takes 
place in the left ventricle (80 per cent.) where the pathological factors 
(v. s.) come most into play; it occurs less frequently in the interven- 
tricular septum, right ventricle and auricles. Sudden death may occur 
without prodromes, or death may result after a few hours to eleven 
or seventeen days. The symptoms are a sense of something giving 
way in the chest, great precordial pain, incoercible vomiting or diar- 
rhoea, cerebral anaemia or irritation of the vagus from haemopericar- 
dium, collapse, and death from pressure of the blood on the venae 
cavae (Cohnheim) or on the heart. Haemopericardium (q.v.) may be sus- 
pected because of greatly increased triangular dulness, faint heart tones, 
and absent or weak apex beat within the left border of the dulness. 

Diagnosis and Treatment. — The diagnosis is rarely made. It 
depends on (a) the etiology, (b) increased dulness, (c) cardiac insuffi- 
ciency, and {d) symptoms of internal hemorrhage. The outlook is bad, 
and the treatment wholly symptomatic; the most absolute rest should 
be enforced. 

Heart injury was first operated on by Farina (1896). The first 
cardiorrhaphy for rupture was by Rehn (1897). Frazier (1906) 
collated 102 operations for injury, of which 42 per cent, recovered. 

Disease of the Coronary Arteries. — This has been sufficiently consid- 
ered under myocarditis (heart aneurysm) and rupture of the heart. 
It will be considered again under angina pectoris, which anatomically 



TUMORS OF THE HEART 451 

belongs to disease of the heart muscle though it is usually described 
under cardiac neuroses. 



TUMORS OF THE HEART. 

These are most rare because the heart is rather insusceptible even 
to neoplasms in its immediate vicinity. They cannot be diagnosticated. 
Carcinoma and sarcoma are the most frequent, and lipoma, myxoma, 
fibroma, and myoma, are infrequent. They are usually secondary. 
Cardiac insufficiency, valvular compression or other disorder and em- 
bolism sometimes develop. 

Parasites are most often accidental post mortem findings. In 
Mosler's monograph echinococcus is the most frequent and occurs 
twice as often in the right ventricle as in the left. Grulee (1905) 
collected 55 cases of echinococcus of the heart. Cardiac rupture, 
sudden death from occlusion of the pulmonary trunks, relative pul- 
monary insufficiency, or cardiac incompetence may occur. The cysti- 
cercus, the pentastomum and trichina are of purely anatomical interest. 



SYPHILIS OF THE HEART (See Syphilis). 
CARDIAC THROMBOSIS— THROMBOSIS CORDIS. 

This usually occurs at the time of or after death, and is of little 
clinical interest. 

Symptoms. — (a) Entire latency. (6) Thrombosis sometimes de- 
velops during life and leads to pulmonary or arterial embolism, (c) 
Sudden cardiac weakness, (d) Sudden valvular stenosis, a ball throm- 
bus (kugelthrombus) forming in the auricle, and occluding, for instance, 
the mitral orifice; it is beyond clinical recognition, although ac~ 
cording to von Ziemssen, it is frequently associated with gangrene 
of the lower extremities; in Curschmann's case an ascites resem- 
bling chronic peritonitis was the sole finding. 



NEUROSES OF THE HEART. 

PALPITATION OF THE HEART. 

Palpitation is also known as cardiopalmus, cardiogmus, or hyper- 
kinesis cordis, and is purely a symptom. In health and in many cases 
of severe heart disease the patient is not conscious of his heart-action. 



452 DISEASES OF THE CIRCULATION 

The most extreme irregularity (delirium cordis), or the pounding heart 
caused by aortic insufficiency, may escape the patient's notice, though 
the normal heart's action may cause palpitation after overwork, from 
abuse of coffee and other causes. 

Etiology. — 1. Nervous Causes (Hyperesthesia of the Centripetal 
Fibers from the Heart to the Brain). — Nervous excitability is common, 
especially in medical students, whose hearts must therefore be examined 
repeatedly when they first study physiology or physical diagnosis. 
Even physicians are not wholly free from heart egotism. Peter Frank 
had violent palpitation while writing his " Diseases of the Heart," 
so that he thought he had aneurysm. It is common in school chil- 
dren, and results from nervous tension, fear of examinations and 
public exercises. It is more frequent in women and may be connected 
with puberty, the climacteric, or menstruation. It occurs almost con- 
stantly in exophthalmic goitre and very commonly (50 per cent.) in 
neurasthenics, so that a special neurasthenia cordis has been recog- 
nized, which is attended by turgid face, red eyes, contracted temporal 
arteries, and angioneurotic oedema, which symptoms disappear when 
the seizure is over. Hysteria is a less important cause. Nervous 
exhaustion, chlorosis, pernicious anaemia, acute infections, lactation, 
poor hygiene, the beginning of tuberculosis, and sexual excess or per- 
version, may produce palpitation. The "irritable" heart of soldiers, 
observed by Da Costa in our Civil War, which is associated with 
arrhythmia, diarrhoea, emotional causes, and physical strain, is often 
placed under this head, but is better classified as muscular insufficiency. 

2. Reflex Causes. — This type might be included under nervous 
palpitation. It follows dyspepsia, especially after a heavy meal, and 
peptones or other products of digestion have been thought causal. 
Dyspepsia may cause it by mechanical gastric distention or by toxaemia. 
It may also result from constipation, intestinal parasites, gall-stones 
(Kehr), renal calculi (Potain and Houchard), puncture of ascites, 
prostatic, uterine, or ovarian disease, floating kidney, and diseases of 
the teeth and nose. 

3. Toxic Causes. — Palpitation may result from the use of coffee, 
tea, alcohol, tobacco, narcotics, and from gout. 

4. Cardiac Causes. — Palpitation may occur in organic heart disease, 
viz.: valvular disease, acute myocarditis, hypertrophy, dilatation, 
coronary atheroma, and in obesity. It may be symptomatic of heart 
failure, as in the heart of nephritics. 

Symptoms. — The patient complains of "feeling the heart beat," 
"goneness," "fluttering," forcible, irregular, or intermittent action of 
the heart, dyspnoea, anxiety, vertigo, tinnitus, and spots before the 
eyes. In some instances, the symptoms recur periodically. Inter- 
mittent epigastric throbbing is not infrequently present. Vasomotor 
symptoms, as flushing of the face, spastic urine, etc., are not uncommon. 

Physical Examination. — Sometimes the heart is absolutely normal. 
Conceptions of palpitation differ widely, and some authors describe 
it under tachycardia. The heart's rate is often increased, going up 



PALPITATION OF THE HEART 453 

suddenly after exertion or fright to 100 or 150, with violent arterial 
throbbing. The increased rate may be due to stimulation of the 
accelerator nerves or of the vagus. The heart is rarely slowed, as in 
Binswanger's case. The rhythm may be normal or disturbed. A 
series of rather rapid beats followed by a series of slower beats is 
possibly somewhat characteristic of nervous palpitation. If the pulse 
is irregular when the patient is quiet it sometimes becomes regular 
after exertion. The first apex tone is often accentuated, is even metal- 
lic, or may be heard by the patient, or by the physician at some dis- 
stance from the patient's chest. In some nervous subjects the systole 
sounds short (Muller). The second tone at the base is more often 
strong than weak. A murmur over the pulmonary region is usually 
functional. 

Diagnosis. — (a) The etiology is of the greatest importance. It is 
confirmed by (b) negative results of examination of the heart during 
the attacks, but particularly in the intervals. Coronary disease, arterio- 
sclerosis, myocarditis, etc., are usually excluded with ease, but it 
should always be remembered that nervous palpitation may co-exist 
with organic difficulties. Palpitation is held by some to lead to dila- 
tation or hypertrophy, but this is probably confusion of cause and 
effect, (c) If pain be present in nervous palpitation, it is more often 
lower (an "epigastric cramp") than that of organic lesions, the pain 
of which radiates to the shoulder or arms. 

Prognosis.— Though palpitation is sometimes lifelong, the outlook 
is generally favorable, but this depends on the etiology. The old 
belief that fright could cause death is as unfounded as most popular 
conceptions, and few such instances are recorded (Bollinger, Laache). 

Treatment. — Treatment must be based on the cause, (a) If the 
cause is nervous, suggestion is valuable and repeated examinations of 
the heart and body are essential, in order to assure the patient and to 
avoid error. Regulated exercise, tepid baths with active friction, light 
meals, regular habits, and possibly the rest cure of Mitchell, are indi- 
cated. It seems from personal experience that isolation often in- 
creases introspection. In anaemic cases full doses of iron, arsenic, and 
strychnine should be given. GoddelFs combination of the three vale- 
rianates is valuable: 

Ferri valerianatis. 

Quininse valerianatis. 

Ammon. valerianatis aa gr, xx. 

M. et ft. in pil. xx. 
S. — One pill after meals. 

In cases of violent throbbing, a few doses of veratrum often quiet the 
general and cardiac nervousness. A belladonna plaster or a few drops 
of the fluidextract helps the patient greatly by anaesthetizing the 
peripheral fibers of the vagus. Sexual hygiene must be strictly 
observed. 



454 DISEASES OF THE CIRCULATION 

Fluidextr. veratri gtt. x. 

Fluidextr. belladonna? gtt. xv. 

Aquse q.s. ad oj- 

M. et S. — One teaspoonful every half hour for two or three doses. 

(6) When the case is reflex, flatulency and constipation must be treated 
and the nose sometimes should be cauterized. Bromides are of value 
but must be given well diluted or in pepsin elixir, in order to avoid 
added gastro-intestinal disorder. 

Sodii bromidi 5j- 

Spts. amnion, aromat Bss. 

Syr. zingiberis 5iij. 

Aquae q.s. ad oij • 

M. et S. — One teaspoonful in hot water every half- hour for four doses. 

A light evening meal of non-nitrogenous food is beneficial in children 
afflicted with night terrors or palpitation, (c) The toxic type is easily 
treated when the noxa is recognized, (d) In cardiac disease, the car- 
diants, morphia, belladonna, aconite and the ice-bag are indicated 
(v. Valvular Disease). Digitalis is of little use in the truly nervous 
type. 

TACHYCARDIA. 

Definition. — Tachycardia is the usual term for rapid heart action, 
although polycardia and pyknocardia are better etymologically, for 
tachycardia implies quick (not rapid) heart action like the pulsus celer. 
Tachycardia, like palpitation, is only a symptom. Some hearts nor- 
mally beat 90 to 100 (120 in the case of Congreve). 

Etiology. — Larcenia's division, somewhat modified, is as follows: 
(a) Heart and vascular disease, coronary or valvular affections, and 
acute or chronic myocarditis, (b) Nervous affections, (i) brain and 
cord disease, as of the medulla (vagus centre), tumors, softening, 
hemorrhage, multiple sclerosis, acute ascending paralysis, bulbar 
paralysis, injury especially to the cervical spine, myelitis and tabes; 
(ii) neuritis, compression of the trunk of the vagus by tumors, irri- 
tation of the accelerator nerve, neuroses as exophthalmic goitre, 
emotional tachycardia, and reflex tachycardia from uterine or ovarian 
disease or from the menopause, (c) General diseases such as fevers, 
chronic troubles (tuberculosis, cancer); and convalescence, exhaustion 
or excesses, (d) Toxic causes, resulting from tea, coffee, alcohol, lead, 
digitalis, atropine, amyl nitrite, etc. Cases are recorded (Tarchanoff) 
in which individuals by voluntarily moving the ear or skin muscles of 
the neck can raise the heart's rate, through the spinal accessory nerve 
and the vagus. 

A special variety is the tachycardia paroxysmalis, described first by 
Proebsting (1881) and later by Nothnagel, Bouveret, and Martius. 
Paroxyms of rapid heart action occur abruptly, last from a few seconds 
or minutes to days or even weeks, and usually end abruptly. This 



TACHYCARDIA 455 

type is seen mostly in strong, hard-working men, who indulge in ex- 
cesses in alcohol, tobacco, etc. Broadbent saw a case at ten years of age. 

The pulse becomes small, is usually weaker and soft, and its rate 
reaches 150, 250 (Bowles), or even 280 (Bristowe). It is at times strong 
(Brieger, Nothnagel) and is usually regular, though arrhythmia may 
develop at the beginning and end of the seizure. The sphygmogram 
reveals more beats than does palpation. The heart often dilates 
(Martius), for the tachycardia and dilatation are coordinate to the 
causal factor. The pause of the heart (the time between systoles) is 
lessened (Francois Frank) and the systole is incomplete. The systolic 
tone is often clicking. The apex is apparently strong, but throbbing is 
an index of weakness and dilatation. Embryocardia (Stokes, Huchard) 
is sometimes present while heart murmurs are rare. The vessels, 
especially the carotids, pulsate violently, and the patient is anxious, 
depressed, and frequently shows signs of venous stasis or cyanosis, 
although the face is at times flushed. The urine is of low specific 
gravity. The lungs are usually normal but Riegel, Tuczek, Edinger 
and Kredel, describe an acute distention of the lungs like that observed 
in valvular disease, which may be caused by vagus or phrenic irritation 
or tonic contraction of the diaphragm. 

Diagnosis. — Permanent tachycardia suggests organic disease of the 
centres in the medulla or nerve trunks. The physiology of the vagus 
and accelerator nerves from the clinical standpoint is still obscure. It 
has been held that (a) increase in the pulse up to 120 indicates sympa- 
thetic irritation (accelerator stimulation), which is relieved by mor- 
phine; (b) increase from 120 to 180 indicates paralysis of the vagus, and 
this is relieved by pressure on the vagus trunk; (c) increase over 180 is 
indicative of sympathetic irritation in addition to paralysis of the vagus. 
Sympathetic symptoms may prevail, as protrusion of the eyeball, wide 
pupils, and increase in the interpalpebral fissure; other evidences of 
vagus involvement may exist, such as respiratory, laryngeal, or gastric 
symptoms. The diagnosis of vagus neurosis rests upon (a) the exclu- 
sion of organic heart and brain disease, (b) a high pulse rate, e. g., 150; 
(c) occurrence in paroxysms with intervals of normal pulse rate; (d) 
inhibitive action upon the paroxysm of manual compression or of 
electrical stimulation of the vagus. 

Prognosis. — The prognosis varies with the cause and type; the 
permanent variety is less favorable than the paroxysmal and temporary 
forms. The outlook is generally good. Bouveret holds that permanent 
cure is rare and has reported four cases of sudden death. The infre- 
quent autopsies (only 14 in 135 cases collected by Hoffmann in 1900) 
show degenerations, etc., in the heart muscle. It is well to regard with 
doubt and caution all cases of tachycardia other than those resulting 
from emotional causes. 

Treatment. — Stimulation of the vagus is effected by faradization of 
the neck, holding of the breath, by Valsalva's experiment, by pressure on 
the right vagus, the use of the ice-bag, lying down, swallowing ice, or by 
induction of vomiting by apomorphine. Morphine, asafcetida, valerian, 



456 DISEASES OF THE CIRCULATION 

and the bromides, are frequently of value. The causal factors must 
receive consideration. 

BRADYCARDIA. 

Definition. — Bradycardia, spanocardia or brachycardia is the usual 
term for slow heart but oligocardia is a better designation. A pulsus 
tardus is normal to some individuals and in certain families may be 
seen in successive generations. It is often an accommodative effort as 
in aortic stenosis. The apparent pulse rate must be verified by cardiac 
auscultation because the pulse record is often but half as frequent as the 
actual heart rate. The pulse rate may fall to 20 or even to 6 beats a 
minute. Paroxysmal bradycardia may occur with weak heart, palpi- 
tation, difficulty in breathing, or gastric distress. 

Following Riegel's classification, two types are distinguished: (1) 
Physiological bradycardia, which is rather infrequent in occurrence; 
it is observed in starvation, and during the puerperium; the rate is 
from 34 to 60. (2) Pathological bradycardia may show 6 to 9 beats a 
minute (Norfleet), and the pulse and breathing may run parallel. 

Etiology. — The etiological factors of the pathological type are: (a) 
Acute infections; bradycardia is very common during or after typhoid, 
pneumonia, diphtheria, and rheumatism. Traube explained the slow 
pulse as due to exhaustion, but it is probably caused by acute myo- 
carditis, which induces lessened conductivity, or "heart-block." (b) 
Digestive disorders, which caused the majority of Riegel's collection; 
jaundice, especially light forms, constipation, gastric cancer or ulcer, 
vomiting (which causes bradycardia and arrhythmia in children), and 
gall stones are the most frequent causes, (c) Respiratory disease is a 
less frequent cause; emphysema occurs frequently with a slow strong 
pulse, which is sometimes an unfavorable symptom, (d) Circulatory 
disease, such as aortic stenosis, fatty heart, coronary atheroma or chronic 
myocarditis, is an etiological factor and lessens the conduction and 
contractibility of the heart muscle. Dehio uses atropine to distinguish 
between (i) disease of the heart muscle, upon which the drug has but 
little effect, and (ii) slow heart due to inhibition of the vagus (trunk or 
centre) in which it brings the heart to or above the normal rate, (e) 
Toxic conditions such as poisoning from lead, alcohol, tobacco (coronary 
spasm), canned meats, coffee, muscarine, digitalis and other drugs may 
cause bradycardia ; it also occurs in cholsemia and early in ursemia, in 
which cases it is unfavorable. (/) General troubles are also causative, 
such as diabetes, cachexia, ansemia or exhaustion, all of which lessen 
the irritability of the heart muscle, (g) Nervous conditions, fright, 
apoplexy, epilepsy, meningitis, brain tumor, disease or injury of the 
medulla or cervical cord, general paralysis, melancholia, hysteria, vagus 
stimulation by tumors, and compression of the vagus trunk, are also 
factors in its development. Jacob describes an angiospastic form 
(bradycardia with chills, wide pupils, cold skin, loud second aortic 
tone, etc). 



BRADYCARDIA 457 

The Adams-Stokes syndrome (described under fatty heart) results 
chiefly from arteriosclerotic changes in the medulla and heart, but 
rarely from toxins or neuroses. The causal condition is " heart block," 
in which the transmission of the peristaltic contraction wave from the 
auricle to the ventricle is " blocked " ; the ventricles contract two to four 
or more times less frequently than the auricles, whose movements may 
be seen in the pulsating cervical veins or by the fluoroscope. The 
syndrome consists of (i) bradycardia (with arrhythmia and hemi- 
systole); (ii) cerebral disturbance (syncope, apoplectiform or epilep- 
tiform seizures); and (hi) accessory symptoms (Cheyne-Stokes 
respiration, angina pectoris, etc.). 

In 1903 His, junior, found a band-like muscular bundle connecting 
the auricles and ventricles, which is known as the " bundle of His. " It 
measures 18 millimeters in length, 2.5 millimeters in width, and 1.5 
millimeters in thickness, and courses posteriorly in the septum ventric- 
ulorum, whence it reaches the right auricle and its valves. According to 
Erlanger (1906), slight compression of His's bundle increases the inter- 
ventricular pause; marked compression causes intermittency in the 
ventricular contractions; complete compression results in independent 
contraction of the auricles and ventricles. In " heart-block " the vagus 
loses control of the ventricle but the accelerator does not. The epilepti- 
form attacks of the syndrome are due to cerebral anaemia and the 
apoplectiform attacks result from cerebral venous congestion. In a 
case of the writer, myofibrosis was found; in the case of Stengel, an 
endocarditic patch ; and in the case of Jellick, Cooper and Ophuls, a 
focus of acute anaemic necrosis (myomalacia cordis.). 

Prognosis. — The constant is less favorable than the paroxysmal type. 

Treatment. — The causal therapy alone is of value. Morphine and 
atropine have been recommended, but must be given with care where 
there is disease of the central nervous system. Strong cardiants, such 
as digitalis, are usually contra-indicated and in the Adams-Stokes 
syndrome are actually dangerous. Alcohol is injurious. In the Adams- 
Stokes syndrome, nitroglycerine is indicated, while bromides are 
deleterious. 

ARRHYTHMIA. 

In an irregular heart the individual beats are irregular in rhythm, in 
strength, or in both. 

Etiology. — The cases are (a) nervous, (i) resulting from brain 
disease, as meningitis, concussion, or pressure from hemorrhage or 
tumor, (ii) psychical, (iii) reflex, usually from the digestive tract, lungs 
and kidney; or (b) cardiac, (i) toxic, from tobacco, alcohol, tea, coffee 
or digitalis, or (ii) organic, from changes in the peri-, myo- or endocar- 
dium. Changes in the heart ganglia, which have been considered 
causes, are probably in most cases the result rather than the cause. 
The recent studies of Gaskell, Englemann, Mackenzie, and Wencke- 
bach, have shown that the heart's function resides in the heart itself 



458 DISEASES OF THE CIRCULATION 

(myogenic contractility, conductivity, excitability, tonicity, and rhyth- 
micity). 

Varieties. — Varieties are distinguished as follows : (a) Intermittence. 
The dropping of a beat may be complete or rudimentary (a slight in- 
dication of the deficient systole is recognized in a faint first tone). Some 
persons can voluntarily drop a beat by contracting the neck muscles, 
probably through reflex action upon the vagus by the spinal accessory 
nerve which supplies the muscles (Donders). (b) Delirium cordis, in 
which the greatest irregularity prevails — "folie cardiaque." (c) Embryo- 
cardia, the fcetal heart rhythm of Stokes, and (d) the gallop-rhythm of 
the heart in cases of renal disease, hypertrophy, etc., which has been 
described under Dilatation, (e) The alternate heart beat, in which a 
strong heart beat is followed by a weak one, with corresponding findings 
in the pulse (pulsus alternans) . When the irregularity recurs at even 
intervals the term allorrhythmia is employed. (/) The bigeminal heart 
beat consists of a strong beat quickly followed by a weaker one, with a 
pause before the next similar group ; the second beat is often weak, and 
may not reach the radial vessels; this variety occurs frequently in 
mitral disease and in the cumulative effects of digitalis. The trigeminal 
heart beat and pulse are similar, except that each group comprises three 
beats. They usually indicate heart weakness, (g) The pulsus para- 
doxus, intermitting with inspiration, has been considered under con- 
cretio cordis (v. Pebicardhts). It may be marked in young persons, 
in convalescence, neurasthenia and brain disease. 



ANGINA PECTORIS. 

Angina pectoris (stenocardia, breast-pang) was first described by 
Heberden and then by Hunter. Edward Jenner first recognized the 
connection between angina pectoris and coronary disease. By far the 
best treatises are Osier's classic on Angina Pectoris and Allied States, 
and Neusser's Heft 2, Ausgewahlte Kapitel der klinischen Symptom- 
atologie. 

Definition. — An arteriosclerotic cardiopathy, characterized (a) by 
paroxysms of excruciating pain over the heart, which radiates to the 
neck and arms, (6) by mental anguish, a sense of dying, and (c) fre- 
quently by sudden death. 

Etiology and Pathology. — The chief and practically constant patho- 
logical finding is arteriosclerosis involving the heart muscle directly by 
coronary atheroma, or indirectly by plaques in the aorta at the coronary 
orifices. The aorta is often atheromatous without coronary involve- 
ment and coronary sclerosis is frequent without much change in the 
aorta. 

Though it is usually described under cardiac neuroses, its proper 
place is under arteriosclerosis. It is notable that atheroma is frequent 
and angina pectoris is rare. The etiology is that of arteriosclerosis 
(q. v.), syphilis, gout, alcohol, contracted kidneys, sometimes infections 



ANGINA PECTORIS 459 

such as rheumatism or influenza. A history of its occurrence through 
several generations of a family is sometimes elicited. It occurs chiefly 
in men (80 to 90 per cent: of cases or more), usually after the fortieth 
year (although cases in the second decennium have been reported) and 
in the well-to-do classes, professional men, hard workers, and luxurious 
livers. Angina is far more common in private than in hospital practice. 

Symptoms. — Mode of Onset. — (a) In some cases the onset is 
gradual, and is preceded by dyspnoea (especially when dressing or un- 
dressing, lacing the shoes, emptying the bowels, sitting up, or beginning 
to exercise), by short deep respiration, precordial oppression, pul- 
monary oedema, bronchial catarrh, strong beating in the second or 
third left interspaces, and difficulty in moving the left arm. This 
cardiac weakness ("cardiac asthma"), is followed by genuine angina. 
Heart weakness and angina are coordinate phenomena, secondary to 
coronary disease. (6) In other cases angina is the first important symp- 
tom of cardiac disease. It is excited by (i) muscular effort, as walking 
up hill; (ii) mental excitement, as anger or coitus; (hi) chilling or bath- 
ing; (iv) flatulent dyspepsia or overloading the stomach, which may 
induce the attack when the patient is quiet or just going to sleep, (c) 
Death may be the first symptom. 

Paroxysm. — The attack itself consists of (1) sudden agonizing pain, 
which is lancinating and feels like an iron hand squeezing the heart. 
Its explanation is disputed and nearly one hundred theories have been 
elaborated. The pain emanates from the cardiac plexus lying behind 
the aorta, and in the nerve branches from it to the coronary arteries, 
whence its reflection to other parts, which will be mentioned later. The 
best explanation, pathologically, is that during the seizure the heart 
muscle is ischemic from coronary obstruction or possibly from super- 
induced spasm of the vessel (Allan Burns, Potain). In man and in the 
horse, atheroma or thrombosis of the abdominal aorta or its branches 
to the legs, shuts off the blood necessary during exertion ; with moderate 
exercise the collateral circulation is sufficient, but prolonged exertion 
produces tingling, cramps, and transient paraplegia ("intermittent 
claudication"). The heart-pang is caused by an analogous coronary 
ischemia when unusual stress is thrown on the diseased coronaries. 
In the case of the author's father, two seizures of angina were followed 
by "claudication," albuminuric retinitis and the Adams-Stokes syn- 
drome; the abdominal aorta was clearly to be seen and felt as a hard 
uneven rigid tube. The "unutterable" pain is usually substernal and 
radiates to the left shoulder, neck and arm. Irradiation may be 
observed to the chin, ear, jaw, occiput, larynx, and even to the gall- 
bladder and renal region, spine, stomach, left leg and testis (which may 
swell). In aortic disease, pain is propagated to the first four dorsal 
areas; in angina it also reaches the cervical and lower dorsal areas. 
Pain along the ulnar nerve to the fingers may precede the angina : 
it is usually associated with some motor weakness and, in Eichhorst's 
remarkable case, with ulnar atrophy. Numbness or hyperesthesia of 
the arm, chest, or mammary regions is frequent. The anginal pain 



460 DISEASES OF THE CIRCULATION 

produces vasomotor symptoms, such as great pallor, low temperature, 
and profuse sweating. The patient may fall, perhaps in a fatal 
syncope, or more often may support himself for a few seconds or 
minutes until the paroxysm has passed. 

(2) The mental anguish, the angor animi, which was first recognized 
by Latham, is the second element of the seizure and consists of a sense 
of dying, with great anxiety, complete consciousness, immobile attitude, 
and perhaps inability to articulate. 

(3) The danger of sudden death is the third element. Death may 
come without pain, in syncope (syncope anginosa) in the first seizure, 
after subsequent seizures which may occur years after the initial 
paroxysm, or after constantly and closely repeated attacks (the etat 
angineuse of Houchard, which is analogous to the status epilepticus). 
Osier has called the anterior branch of the coronary artery the "artery 
of sudden death. " Death in angina is analogous to death from experi- 
mental injury to Kronecker's point in the septum. It usually occurs in 
the second or third attack. 

Other Signs and Symptoms. — The heart is variable, is sometimes 
normal in rate and strength, and again shows a tense or weak, slow or 
rapid, or irregular pulse. The left radial may be smaller than the right. 
A slow pulse usually results from partial " heart-block. " Dunin found 
the arterial pressure low in 45 per cent, and high in 20 per cent, of his 
cases. Delirium cordis, gallop-rhythm, and shortening of the long 
pause, are but signs of cardiac fatigue. 

The second aortic tone is often loud and metallic; a rough or blowing 
systolic (and sometimes a diastolic) murmur is heard over the aorta, 
which is sometimes dilated ; and the left ventricle may be dilated, thus 
sometimes relieving the attack by relative mitral leakage (Broadbent 
and Musser). These incidents are simply evidences of arteriosclerosis 
and its sequences. Constitutional disturbance very frequently occurs, 
as disturbance in nutrition, loss in weight, color, and physical endur- 
ance. Dyspnoea is not a part of angina pectoris, but is solely sympto- 
matic of heart insufficiency. Involuntary evacuations or unsuccessful 
straining at stool are not very frequent. The urine is often pale and 
abundant after the seizure. Dysphagia, singultus or gastric symptoms 
are due to sympathetic participation of the pneumogastric and phrenic 
nerves. 

Diagnosis. — When the attack is typical and severe, there is little 
difficulty in making a diagnosis. Mild or early attacks may be confused 
with cardiac asthma, because angina may be preceded by cardiac 
distress, or associated with it. Seizures of angina involving the ab- 
domen (angina abdominis) or legs (angina cruris) are easily mistaken 
unless the case is closely watched; these forms may appear first or may 
alternate with the more usual type — angina pectoris. The classical 
picture, together with hardness of the arteries and atheroma of the 
aorta or aortic valves, makes the diagnosis practically certain. The 
respiration is essentially normal during the attack. Atheroma with 
cardiac asthma is not angina pectoris. 



ANGINA PECTORIS 461 

Pseudo-angina (Latham and Walshe) is the most frequent cause of 
diagnostic error. Its varieties are (a) nervous pseudo-angina, which 
occurs in cases of neurasthenia and hysteria, in other neuroses, and in 
the crises of tabes (which in Oppenheim's case was due to vagus 
neuritis). Huchard's widely quoted table is substantially as follows: 

True Angina vs. Pseudo- angina. 

Most common in men between forty and Commonest in women, at any age. 
fifty. 

Paroxysms induced by exertion, etc.; Spontaneous; often nocturnal and 
diurnal; few in number. periodic; frequent. 

Pain intense, of short duration, pre- Less severe, lasting hours; epigastric; 

cordial, inarticulate; immobile atti- agitation, activity; sensation of disten- 

tude; sensation of cardiac compres- tion. 
sion. 

No nervous symptoms. Neurasthenic or hysterical stigmata. 

Vasomotor form rare. Common. 

Prognosis grave or fatal. Never fatal. 

Lesions: from coronary sclerosis. From neuralgia. 

Arterial medication. Neuralgic medication successful. 

(b) Vasomotor angina (Nothnagel) which is not uncommonly at- 
tended by vasomotor spasm, coldness and numbness in the extremities, 
a feeling of faintness and great pain in the heart. It may be reflex in 
origin. 

(c) The toxic pseudo-angina (Beau, Graves and Stokes) is due to 
coffee, etc., but especially to tobacco. Vasomotor symptoms, amau- 
rosis, dyspepsia, weak, rapid, or irregular heart action, palpitation, and 
anginal pain are common. Functional angina from tobacco, which 
results according to Huchard from coronary spasm, heals when 
tobacco is withheld; but actual coronary disease, due to tobacco and 
other heart poisons, is not curable, (d) The crises of tabes and pre- 
cordial pain due to brachial neuritis, vagus involvement or gout, etc., 
may be difficult to diagnosticate. 

The prognosis is self-evident. Death is frequent. In one instance 
the patient lived forty years. Few clear recoveries are reported. 

Treatment. — The treatment concerns (a) the etiology, in which 
arteriosclerosis is the essential factor. Vierordt advises that the possi- 
bility of syphilis should always be considered. Gout and diabetes 
necessitate appropriate diet and therapy, as colchicum. Attention 
must be directed to the question of stimulants. Aside from syphilis, 
the iodides are valuable and should be given two-thirds of the time, for 
months and years. Small amounts are frequently tolerated less well 
than 10 or 20 grain doses. Care in their use is necessary in nephritis, 
and even when they are well diluted gastric disorder may result and 
possibly induce an attack of angina. Nitroglycerine or its derivatives 



462 DISEASES OF THE CIRCULATION 

are indicated in the intervals, in doses of gr. roo to ^ four or more 
times daily, but it should be remembered that its effects last less than 
an hour. It may cause headache, flushing, or (in larger doses) cyanosis 
or pallor, muscular relaxation, dyspnoea and irregular pulse. Erythrol 
tetranitrate in doses of gr. ss. t. i. d. has a more lasting effect than 
nitroglycerine. These vasodilators will be again considered under 
Arteriosclerosis, (b) The causes precipitating paroxysms. Pro- 
phylaxis should be maintained regarding (i) exertion, (ii) excitement, 
worry, (iii) coitus, (iv) chilling, (v) constipation, and (vi) dyspepsia; 
late suppers and foods favoring flatulency should be avoided, and 
a light evening meal should be taken. The patient should be provided 
with a mixture of aromatics in order to dispel gastric flatulency; a single 
dose is contained in the following: 

Spiritus ammonias aromatici 3ss. 

Spiritus chloroformi 5ss. 

Spiritus glycerylis nitratis gtt. i. 

Spiritus aetheris compositi 3ss. 

M. et S. — To be taken in hot water. 

(c) The paroxysm. Amyl nitrite was first advised by Brunton; it is 
an analgesic and a vasodilator; the patient should carry pearls of the 
drug, which were invented by Solger and contain three minims of the 
remedy. They often operate powerfully and instantaneously, though 
sometimes they are useless. It may be better to have the patient chew 
a hypodermic tablet of nitroglycerine grain - x ho, for the physician but 
rarely sees the attack. Some member of the patient's family should be 
taught how to give a hypodermic injection of morphine. Morphine and 
chloroform inhalations have been held dangerous, especially when 
brain trouble exists, as is sometimes the case in the Adams-Stokes triad. 
Nevertheless they must be used in some cases. Yeo called attention 
to the large doses of morphia required and tolerated by subjects having 
angina, (d) Cardiac weakness, which is treated by diffuse stimulants, 
such as ammonia, camphor, alcohol and strychnine. When arterial 
tension is low, digitalis may be administered between paroxysms : 

% 

Tr. digitalis 3iv. 

Tr. strophanthi 5ij- 

Tr. Valerianae q.s. ad oiv. 

M. et S. — One teaspoonful after meals. 

Vierordt says that morphine should be carried in one hand and 
stimulants in the other. Coffee is said to be prophylactic against cardiac 
weakness and the paroxysms. Pseudo-angina is treated according to 
the type. Electricity and arsenic are valuable. 



ARTERIOSCLEROSIS 463 

DISEASES OF THE AETERIES. 

ARTERIOSCLEROSIS. 

Synonyms. — Atheroma, arteriocapillary fibrosis (Gull and Sutton), 
endarteritis deformans (Virchow), angiosclerosis (Thoma). 

Definition. — A regressive change, evidenced first by malnutrition in 
the walls of the large or small vessels and later by compensatory 
thickening, either localized or diffuse. 

Etiology. — 1. Age. — Arteriosclerosis is the essential element in 
senile involution, although some individuals attain their hundredth year 
with no arterial change. Though usually found after the fiftieth year, 
hereditary influences or certain infections, as syphilis, may develop 
hard arteries between the twentieth and fortieth year. Thoma fre- 
quently found a moderate degree of hardness after the thirty-sixth year. 
In adolescence or even in infancy it is sometimes found as a result of 
the acute infections; Chiari found it in 27 per cent, of those under 25 
years. 

2. Sex. — Eighty per cent, of cases occurs in men, from causes to be 
enumerated below. In women it usually occurs a decade later than in 
men. In factory women over fifty, Jusserand found even a larger per- 
centage than in men. 

3. Arterial Poisons. — Chronic alcoholism causes 25 per cent, of all 
cases (Edgren); it is not known how the arterial poisons operate; they 
do not raise arterial pressure; coffee, tea, and tobacco (which is said to 
affect especially the coronary vessels), are causative factors. Angio- 
sclerosis has been produced experimentally by adrenalin. 

4. Overwork. — This is second only to alcohol in importance. Phy- 
sical exertion brings one-third of the circulating blood to the muscles, 
thus lowering the tension in other vessels (v. i. Thoma's Theory). 
According to an older theory exertion raises arterial tension. 

5. Poisons Produced Within the Body by Perverted Metabolism. — 
Interstitial nephritis bears a threefold relation to arteriosclerosis: (a) 
it results from diffuse arterial hardening; (b) it raises arterial pressure 
mechanically (Traube) by increased peripheral resistance in the arter- 
ioles, or by alteration in the quality of the blood (Bright) ; (c) both 
processes are coordinate to a common cause. Gout certainly leads to 
arteriosclerosis. Diabetes bears a double relation, being either a rather 
rare result of arteriosclerosis of the pancreas (Fleiner), and possibly of 
the brain (Grabe), or itself causing arterial hardening. High living, 
overeating, obesity, and overindulgence in meat may be included under 
this head. 

6. Specific Infections. — Edgren and Camac consider syphilis of first 
etiological importance in 33 per cent, of the cases. It operates by 
chronic toxaemia and endarteritis. Tuberculosis (in 16 per cent.) may 
produce changes in the vessels; for instance, tuberculous meningitis 



464 DISEASES OF THE CIRCULATION 

may attack them from the perivascular lymphatics, especially those 
about the middle cerebral artery and its branches. Typhoid, rheuma- 
tism, influenza, scarlatina and other infections are held by French 
writers to have some bearing on vascular sclerosis and endarteritis. 
Oppenheimer has recently described arteriosclerosis in children nine 
and ten years old, obviously due to acute infections. 

7. Other Causes. — Nervous factors (worry, high tension, neuras- 
thenia) cause variations in blood pressure. Excessive brain effort 
tends toward cerebral localization precisely as digestive excesses may 
develop changes in the mesenteric vessels, just as working with the 
arms (as in the case of butchers) may develop changes in the brachials, 
and as excessive walking may produce arteriosclerosis in the femorals. 
Extreme heat, as in the work of bakers and stokers, is thought to induce 
sclerosis. 

Pathogenesis and Pathology. — (A). Thoma considers angiosclerosis 
a compensatory process which follows widening of the vessels and 
alteration of the blood. To restore the caliber of the widened vessels, 
the tunica media contracts, or when it cannot contract, the vessel 
increases in thickness by growth of the subendothelial connective 
tissue of the intima. Thus in the foetus there is no connective tissue 
in the tunica intima, but it appears when the foetal circulation changes 
at birth, new areas of circulation being opened up. All bloodvessels 
have a nervous supply ending in the Vater-Pacini bodies. They respond 
to persistent low pressure, or dilatation, by increased proliferation of the 
connective tissue. Thoma observed arteriosclerosis develop in cases 
of experimentally produced aortic insufficiency. (B). Others regard 
arteriosclerosis as due to inflammation in the nutrient vessels, the vasa 
vasorum, leading to growth of connective tissue (Huchard, Koester, 
Hipp, Martin), i. e., mesarteritis and periarteritis. When arteriosclero- 
sis is seen in vessels with no vasa vasorum, it must be a simple regression 
or degeneration. 

Conceptions of its morbid anatomy differ widely, atheroma of the 
aorta and endarteritis or arteriocapillary fibrosis being sometimes 
described under separate headings, but the difference is rather ana- 
tomical than pathological. Large vessels, such as the carotid, contain 
more elastic than muscular tissue, but the small vessels are largely 
muscular. Two main forms are distinguished, (1) the diffuse, and (2) 
the nodular. Without distinction as to form, Rokitansky found that 
arteriosclerosis occurred in the following order of frequency : ascending 
aorta, arch, thoracic, abdominal aorta, splenic, iliac, femoral, coronary 
(next after the aorta, according to Huchard and Sansom), cerebral, 
uterine, brachial, spermatic and carotid arteries. It is rare in the 
gastric and in the mesenteric and hepatic vessels and least frequent 
in the pulmonary trunk. Bergmann found the two varieties in the 
following percentages : 



ARTERIOSCLEROSIS 465 

Nodular 
Diffuse Form. (nodose) Variety. 

Per cent. Per cent. 

Radial 89 2 

Ulnar 88 8 

Tibial . 87 8 

Popliteal 64 25 

Splenic 64 17 

Femoral 58 14 

Axillary 53 16 

External iliac .... 49 15 

Brachial 49 9 

Subclavian 45 43 

External carotid ... 44 22 

Cerebral 40 43 

Internal carotid ... 28 60 

Ascending aorta .... 19 56 

Common carotid ... 10 69 

Abdominal aorta ... 75 
(Both forms may coexist in the same vessel). 

It will be noted that where the diffuse variety is most frequent the 
nodular form is least observed and that the converse is true. The 
diffuse form is most frequent in the extremities where arterial tension is 
most variable and more collateral circulation prevails; the nodose form 
is most common in the aorta and its primary branches, but is also seen 
in the circle of Willis, where arterial pressure varies greatly (Meynert). 

To the naked eye the intima may be normal and smooth but most 
often is uneven and thickened. Small gelatinous or yellowish fatty 
areas are seen which though at first circumscribed often fuse into large 
plaques; they occur where arterial pressure is greatest, as in certain 
places in the aortic arch (See Aneurysm), or where the vessel divides or 
gives off branches, as the subclavian or intercostal branches. These 
plaques of atheroma or nodular arteriosclerosis represent nature's 
effort to fill out areas of degeneration and dilatation and thus make 
even the caliber of the vessel. Microscopically the intima may be 
increased three or four fold from swelling of its tissue, increase of 
connective tissue and round-cell infiltration. Granular detritis, fatty 
needles and cholestearin plates are seen in the atheroma plaques, a 
name indicating their pulpy, grumous appearance. Formerly they 
were wrongly called atheromatous abscesses. An atheromatous area 
rupturing into the lumen produces the atheromatous ulcer, which may 
cause embolism, thrombosis or occulsion. Secondary deposit of car- 
bonate or phosphate of lime in the atheromatous areas leads to calcifi- 
cation of the arteries or may produce rough areas in the aorta which 
break on manipulation or if handled carelessly may cut the finger. 
The lumen of the smaller vessels is often decreased or obliterated 
(endarteritis obliterans). The middle and outer coats of the smaller 
vessels are at times thickened from hyaline degeneration and fibrous 
tissue; the muscular coat may waste and all elastic tissue may dis- 
appear; the essential changes are those in the elastic tunic. In the 
larger vessels dilatation or even aneurysm may develop where thick- 
ening of the intima fails to protect the vessel wall. 

30 



466 DISEASES OF THE CIRCULATION 

The general results of arteriosclerosis are (1) vascular, and consist of 
loss of arterial elasticity, deformity, tortuosity, obliteration, aneurysm 
and high arterial tension, and (2) visceral, and occur in the heart, brain, 
kidney, and other organs (v. i.). 

Sclerosis in the pulmonary artery is most common in the stasis and 
in the increased pulmonary tension of mitral lesions and emphysema; 
aside from these cases, the older writers maintained that it was always 
the result of general arteriosclerosis. The rare cases of Rhomberg, 
Klob and Xeusser have shown that pulmonary atheroma may occur 
alone, sometimes with aneurysmatic dilatation of its branches and 
with pulmonary regurgitation. 

The term angiosclerosis (Thoma) also includes phlebosclerosis ,which 
frequently accompanies arteriosclerosis and sometimes occurs inde- 
pendently; it is most often seen in the lower extremities and sometimes 
in the lung and in the portal tributaries in cases of liver cirrhosis or 
pylephlebitis. 

Symptoms and Diagnosis. — In diffuse forms there may be no 
symptoms i. e. the process is latent. When it is local, visceral symptoms 
may develop. The clincial picture is extremely variable. 

1. The peripheral arteries may be involved alone or there may be 
changes in the aorta and in the heart, brain and kidneys. The small 
arteries are visible and appear tortuous, pulsating and lengthened, as 
do the temporals or brachials when the elbow is flexed and the arm is 
rotated outward. Lifting the arm is said to decrease the pulsation, 
while this maneovre increases it in cases of aortic regurgitation. A 
distinction must be made between hardness of the vessel walls and 
increased arterial tension, although both conditions usually occur 
together. The normal systolic blood pressure measures 125 mm. 
(Strassburger, Sahli, Fellner) and the diastolic measures 29 mm. 
Dunin holds that the systolic pressure ranges between 130 and 150 
mm., and that 21 per cent, of cases of arteriosclerosis have normal or 
decreased arterial tension. It is asserted that increased arterial tension 
precedes actual sclerosis of the vessels but in these early cases it is 
probable that some angiosclerosis has already developed. Pressing on 
the radial with one finger should obliterate the pulse beyond that point 
if the arteries are not sclerotic, unless there is an anastomotic or recur- 

Fig. 28. 




Pulse tracing in arteriosclerosis. 

rent pulse from the ulnar to the radial vessel; this source of error is 
easily eliminated by simultaneous pressure on the ulnar vessel. The 
wall of the artery is firm, hard, often uneven or nodular, and the serial 
atheromatous plaques sometimes feel like a rosary or the trachea of a 
goose. In extreme instances the vessel feels calcareous — the "pipe 
stem artery. " The Roentgen rays clearly show the arterial change. 



ARTERIOSCLEROSIS 467 

The pulse is hard {pulsus durus), retarded (pulsus tardus), or slow 
(pulsus rams); it rises slowly and is long maintained (p. rotundus), 
the vessel is firm between the pulse beats (Broadbent), the elastic wave 
is lessened or absent, the tracing has a rounded or flat top, and the pulse 
in the two radials may differ (pulsus differens). Marked slowing of 
the pulse calls attention to the coronary vessels. The bigeminal pulse 
is most rare unless there are heart, coronary, or brain changes. In some 
cases, either from vessel obliteration or because the walls are absolutely 

Fig. 29. 



Pulse tracing in extreme arteriosclerosis (Sahli). 

rigid, the pulse cannot be felt. Very slight pressure on the vessels often 
elicits a systolic murmur (Litten). The right radial is normally larger 
and more often shows changes than the left. It must be remembered 
that changes may occur in internal vessels without change in the 
radials (and conversely). 

2. There may be heart changes, (a) Simple hypertrophy of the left 
ventricle may occur, with heaving apex, loud second aortic tone, tense 
pulse, and thickness of the arteries, which lead to a certain and immedi- 
ate diagnosis. Some " consensual " right heart hypertrophy is common 
because of anastomosis between the ventricular muscular fibers or 
because of stasis in the lungs or emphysema. Those cases in which 
there is increased tension in the aorta without increased tension in the 
radials are more difficult of diagnosis. The heart is not hypertrophied 
in all cases nor, according to Rhomberg, in the majority of cases; 
hypertrophy, he maintains, does not necessarily follow arteriosclerosis 
in the extremities or brain, but most often occurs when the splanchnic 
vessels are involved; Hasenfeld also believes that cardiac hypertrophy 
only occurs when these vessels and the aorta are sclerosed. The apex 
may sink outward and to the left when the patient sits, from relaxation 
and lengthening of the aorta (Traube). (b) Hypertrophy plus dilata- 
tion, with heart insufficiency, dyspnoea, scanty urine, and hydrotho- 
rax, is very common. When the patient in this stage has a systolic 
murmur, a wrong diagnosis of mitral insufficiency may be made. Inter- 
stitial nephritis (q. v.) may be the cause, in part at least, of the hyper- 
trophy and dilatation. (Edema is not frequent. Gallop-rhythm is 
uncommon without coincident coronary or renal disease. The heart 
muscle may show various changes, such as atrophy, myocarditis, 
myofibrosis, myomalacia cordis, the cor renale, senile heart, heart 
aneurysm, angina pectoris, coronary embolism, cardiac asthma, fatty 
heart, and arrhythmia, or sudden death may occur. Two forms of 
visceral sclerosis may be distinguished: (a) inflammatory, occurring 
about the vessels, and (b) dystrophic (malnutritive) sclerosis, which is 
often somewhat distant from the vessel involved; the visceral sclerosis 
is best illustrated by the heart changes, such as myofibrosis or myo- 
malacia cordis, induced by coronary atheroma. 



468 DISEASES OF THE CIRCULATION 

3. In the aorta dilatation may occur, giving slight dulness in the 
second {and third) right intercostal spaces; this is confirmed by the 
fluoroscope; the aorta may be felt in the jugulum or abdomen. The 
normal aorta may be felt in these situations when the heart action is 
strong, but when there is atheroma, plaques or even a crackling may 
sometimes be felt. The subclavian, or innominate arteries may be 
felt even through their entire length when the aorta is dilated. A 
short systolic murmur over the aorta often results from atheromatous 
roughening or dilatation, and the second aortic tone is then accentuated 
and metallic. Its vibration may sometimes be felt; when much 
emphysema is present it is best heard in tne jugulum. The 
accentuation may be caused by increased tension, widening, or 
rigidity of the aorta. The murmur and sharp tone are often heard in 
the neck and back. Aside from nervous sensations, a burning pain 
back of the sternum may indicate involvement of the outer coat of the 
vessel. Atheroma of the arch may, by downward extension, cause 
aortic stenosis or more often aortic regurgitation. 

4. Renal findings are next in frequency. The kidneys are often 
contracted (the senile arteriosclerotic kidney and the genuine con- 
tracted kidney). The discussion of the question whether the renal 
findings are primary or secondary is a separate literature in itself (see 
Interstitial Nephritis). The urine may be increased as a result of 
simple increase in the blood pressure. 

5. Brain symptoms are next in importance. Syncope, vertigo, 
insomnia, headache, tinnitus, neurasthenic symptoms, transient 
aphasia or hemiplegia are difficult to explain, though they are said to 
be caused by transient ischsemia. Brain hemorrhage and miliary 
aneurysms are frequent sequences. Softening of the brain (encephalo- 
malacia) results from embolism or thrombosis of the cerebral arteries. 
Brain atrophy, dementia (cortical sclerosis), epileptic seizures and the 
Adams-Stokes triad have been attributed to cerebral atheroma. Vas- 
cular brain lesions occur fairly often in cases which show arteriosclero- 
sis in the extremities and temporal vessels, though sclerosis of the aorta, 
coronary, or splanchnic vessels occurs more often without peripheral 
angiosclerosis. 

Charcot's claudication intermittente (Erb's dysbasia intermittens 
angiosclerotica, intermittent limping, angina cruris) occurs especially 
in nervous or neurasthenic subjects. It is due to atheroma in the ab- 
dominal aorta and its branches in the limbs. It is seen in abdominal 
aneurysm in the horse. Erb, reviewing 127 cases in 1904, found that 94 
per cent, were in men over 40 years of age; heredity is sometimes 
causal: 33 per cent, were Jews; syphilis (in 23 per cent.) was less 
frequently causal than tobacco; alcohol was not proven an etiological 
factor; most cases developed in the upper classes. Pain, paresthesia?, 
and sometimes local cyanosis, occur in the legs, which "give way" 
after moderate exertion. The legs are most comfortable when depend- 
ent. The dorsalis pedis, sometimes also the tibial and femoral vessels, 
usually cannot be felt. Gangrene may result. 



ARTERIOSCLEROSIS 469 

Some of the vasomotor neuroses — as erythromelalgia, Reynaud's 
disease, acroparesthesia — and some forms of neuritis and neuralgia 
are sometimes associated with angiosclerosis. 

6. The g astro-intestinal symptoms probably rank next in frequency. 
Hasenfeld, Huchard, Allbutt, Litten, Edgren and others have described 
dyspepsia, round ulcer, arteriosclerotic gastritis, gastro-intestinal 
hemorrhages, intestinal perforation and ulceration. Severe abdominal 
pain (angina abdominis) has attracted some attention lately; it is due, 
as is angina, to anaemia (Oertner's intermittent claudication of the ab- 
dominal vessels, Schiitzler's intermittent dysperistalsis) ; it develops in 
two or three hours after eating, and is often accompanied by dyspnoea. 
Abdominal angina, in the writer's experience, is rather often associated 
with angina pectoris and angina cruris; in three cases these conditions 
appeared alternately. 

7. The retinal vessels are not infrequently embolized, narrowed, or 
aneurysmatic, which lead to softening, hemorrhage, and exudation. 

8. In the respiratory tract, emphysema is common and is sometimes 
regarded as a compensatory effort. The breathing is often somewhat 
irregular. Haemoptysis is referable to stasis, infarction, or possibly to 
atheroma of the pulmonary arterioles. 

9. In the peripheral vessels the so-called spontaneous or senile 
gangrene results from obliterating endarteritis. Thrombosis or em- 
bolism may occur in the aorta, brain, or in the coronary, pulmonary, 
mesenteric, pancreaticoduodenal and other arteries. 

10. The general nutrition varies. Some writers distinguish between 
(a) a plethoric type, which occurs in elderly individuals and the symp- 
toms of which are good color, wide vessels, increased thirst, hemor- 
rhages from the nose, increased urine, respiratory catarrh, profuse 
sweats, muscular rheumatism, headache, enlargement of the liver, 
emphysema, tense pulse, thick bloodvessels and marked hypertrophy 
of the heart; and (b) an anaemic type, with chlorotic habitus, anorexia, 
dyspepsia, few external vascular findings, dilated heart, and endarter- 
itis. This type occurs in individuals between 30 and 50 years of age. 
French writers speak of a cachexie arterielle, in which the pallor is 
distinguished from the dusky anaemia of cardiac disease. Alfred Sten- 
gel has noted that the anaemia is more often apparent (pseudo-anaemia) 
than real. 

Prognosis. — The prognosis is relatively unfavorable, because the 
symptoms are frequently latent until the process is well established or 
far advanced. In the early stages arteriosclerosis may be arrested or 
may remain stationary for a long period, but there is constant danger 
of apoplexy, angina pectoris, myocardial paralysis, "heart block," 
heart rupture, or uraemia. It is a most common finding after death 
from acute infections, so that many deaths attributed to acute affections 
are more properly deaths from arteriosclerosis. Increased blood pres- 
sure may overcome moderate obstruction. The prognosis is most 
favorable in angiosclerosis of the peripheral vessels, and, as a rule, is 
rather unfavorable in atheroma of the aorta, because of the danger of 



470 DISEASES OF THE CIRCULATION 

coronary disease and aneurysm. Intestinal hemorrhage is ominous. 
A slow pulse is less favorable than arrhythmia and moderate increase 
in rate. The plethoric form is less dangerous than the anaemic. 

Treatment. — Prophylaxis regarding the etiological factors and the 
patient's mode of life is most important. Alcohol and tobacco should 
be forbidden, iodides should be given in syphilis, the diet should be 
regulated in diabetes, colchicum should be given in gout, etc. In early 
cases the process may sometimes be arrested. Many cases seem to im- 
prove on a milk diet, although Rumpf claims that many of the salts 
ingested are deposited in the arteries. He found that milk sufficient to 
meet the needs of metabolism (70 5 or 2,175 c.c.) for 24 hours contained 
over one dram (5 grams) of calcium and magnesium. Iodide of potash 
has been advised, especially by Huchard, who gives 1 to 15 to 45 
grains daily for twenty days; then after ten days intermission, nitro- 
glycerine is used. (See Angina Pectoris and Treatment of Syph- 
ilis for details.) Iodides are also used in cases where no suspicion 
of syphilis exists. Some physicians oppose its use and find on ex- 
perimentation that it has no vasodilator effects. Rosenbach claims that 
it actually irritates the endothelial tissues. In some cases at least it has 
beneficial effects and in a non-syphilitic series of personally observed 
cases the walls of the nodular and hard vessels distinctly improved with 
administration of iodides. Rhomberg thinks that iodides operate less 
as vasodilators than they do to decrease the viscosity of the blood. It 
has been recently claimed that nitroglycerine dilates the peripheral 
vessels only, but on this assumption it is hard to explain the cerebral 
flushing, etc., which follows its use. Massage, a warm climate, passive 
exercise, and the Schott method of treatment may be employed as out- 
lined under Dilatation of the Heart. It is interesting to note that 
Skoda employed hot hand- and foot-baths to reduce peripheral resist- 
ance. Coffee may relieve anginal and abdominal pain. 

Iron and digitalis not only are, as a rule, unavailing but also are 
directly injurious. When the heart action is weak, Huchard advises the 
following pill: 

Sodii iodidi 5j. 

Sparteine sulphatis gr. xv. 

Pulv. glycyrrhizse q. s. 

M. et ft. in pil. xl. 
S. — One after meals. 

Rest is more efficacious than are cardiants. Morphine is a valuable 
nervous sedative and tonic for severe cases of cardiac asthma, but must 
be used with great care. 

ANEURYSM. 

Definition. — A dilation, usually localized and sac-like, of an artery. 

Etiology. — (a) Arteriosclerosis is the most important cause. The 
importance of syphilis is estimated at 29 per cent. (M. Schmidt), 
36 per cent. (Fraenkel), 53 per cent. (Gerhardt), 80 per cent. (Malm- 



ANEURYSM 471 

sten), and 100 per cent. (Drummond). The author thinks the rela- 
tionship between syphilis and aneurysm is as well established as that 
between syphilis and locomotor ataxia, and probably with the same 
percentage, for the majority of cases coming under his own clinical 
and autopsy observation give a clear history or show indubitable stig- 
mata of syphilis. Sudden effort in strong men with a weakened aorta is 
a direct factor in partial rupture of the aorta and formation of aneu- 
rysm, (b) Trauma is an important factor but is probably overestimated. 
(c) Sex: aneurysm is from two to eight times as frequent in males as in 
females, (d) Age: the old statement that aneurysms occur before the 
fiftieth year and arteriosclerosis after that age is still valid ; they occur 
between 30 and 40 (Crisp), 30 to 50 (Orth),"30 to 60 (Rokitansky), 40 
to 50 (v. Schroetter) ; later compilations, however, set the age higher, 
50 to 60 (Emmerich), 60 to 70 (Juda), and even after 70 (Barsdorff). 
It is said that but 60 cases under 20 years of age have occurred, (e) 
Embolic and mycotic aneurysms are usually small and may be multiple. 
Arterial tuberculosis was found by Weinberger. (/) The traction 
aneurysm (Thoma) at the ductus arteriosus Botalli is rare. 

(g) The arrosion aneurysm, in which the inner coats bulge out when 
the adventitia is eroded, occurs largely in tuberculous cavities. The 
"aneurysmal diathesis" is spoken of by older writers; Pelletier found 
63 in one case. Dieulafoy considers that multiple aneurysms of the 
arch are clearly syphilitic. 

Pathology. — In relation to the lumen, aneurysms are axial or periph- 
eral. According to Quain, the varieties are: (a) true aneurysm, in 
which the sac consists of one or more coats. Strictly speaking, a true 
aneurysm should contain all three arterial coats in its walls, but this 
is most uncommon. The sac is usually (i) fusiform and diffuse, or (ii) 
sacculated and circumscribed, (b) False aneurysm, in which all the 
coats rupture, or in which, according to some, one coat ruptures 
through the others, like a hernia. These are circumscribed or diffuse, 
especially in the transverse arch and in the abdominal aorta, (c) 
Dissecting aneurysm, wherein the intima of the vessel ruptures and the 
blood makes a channel down the vessel between the intima and media 
or between the layers of the latter. It is a partial rupture. The rup- 
ture back into the aorta is an attempt of nature toward recovery: the 
patient may live for years, (d) Varicose aneurysm, wherein the sac 
ruptures into a vein, especially the innominate vein or vena cava; this 
form is also called arteriovenous and aneurysmal varix, because the 
main change is in the vein. 

Atheroma is held to be a common cause, though it occurs very fre- 
quently in comparison with aneurysm. It is thought that intimal 
changes induce aneurysm when the outer coats do not undergo vicari- 
ous thickening quickly enough to prevent dilatation. Koester held that 
mesarteritis was the principal change, but Eppinger found the greatest 
change to be loss of the elastic and muscle-tissue in the media. Syphi- 
litic changes are discussed under Syphilis and are very 'important. 
In the sac thrombi form from the roughened intima and slowed circu- 



472 DISEASES OF THE CIRCULATION 

lation and to a small extent guard against extension and rupture. 
Aneurysm occurs at those points in the aorta on which the blood stream 
impacts most strongly; 59 per cent, of thoracic aneurysms occur on the 
anterior surface of the ascending aorta, 29 per cent, on the convexity of 
the arch and 12 per cent, on the posterior surface of the descending 
segment. In 915 aneurysms the seat was in the pulmonary artery in 
but 0.4 per cent. (Crisp). 

Symptoms. — Bramwell distinguishes three classes of cases: (a) 
Those which are entirely latent, and become manifest only by rupture 
or at the autopsy, (b) Those presenting symptoms of intrathoracic 
pressure but giving no positive physical signs, (c) Those signalized by 
distinct physical signs, e. g., by pulsating expansile tumor. 

The Purely Subjective Evidences of Aneurysm. — The clinical signs are 
most variable, and often change or disappear entirely when the aneu- 
rysm changes the direction of its growth; the latency of a large pro- 
portion of aneurysms gives a disproportionate value to symptoms per se. 

1. Pain. — Pain is either intrinsic, resulting from subacute aortitis, 
varying with the arterial tension, relieved by reduction of the circula- 
tion, localized, and dull or aching in character; or it is extrinsic, result- 
ing from pressure on nerve trunks especially in deep-seated tumors, or 
from the weight of the aneurysm, as illustrated by a case of Stokes in 
which pain was relieved by the use of crutches. Pain in addition to 
progressive enfeeblement and emaciation is of some diagnostic value. 
Sudden pain in the left chest, whether anginal or not, if it does not 
yield to treatment, is always suggestive of aneurysm. Pain in the major- 
ity of cases is the first, the most notable, and often the most enduring 
symptom. It is often alleviated by iodides; it is usually paroxysmal, 
sharp, lancinating, or boring in character (when, for instance, the spine 
is eroded); it is augmented by movement, but may cease when the 
part compressed is entirely eroded. The pain is local or is reflected 
into the brachial plexus, the arm, neck, or along the intercostal nerves 
and may cause numbness and paresis of the arm. Though it is more 
usual anteriorly, it is sometimes felt in the interscapular region. An- 
ginal pain follows involvement of the cardiac plexus. Intercostal 
neuralgia is always suggestive of aneurysm. When there is tenderness, 
care is imperative lest palpation induce embolism. 

2. Dyspnoea. — Dyspnoea is frequently out of all proportion to the 
findings. It is often a vagus neurosis, but is also due to narrowing of 
the chest space by compression of the aneurysm upon the heart, 
phrenic nerve, trachea, bronchi, lungs, or pulmonary artery; or to com- 
pression of the plexus cardiacus or pulmonicus, producing bronchial 
spasm, and of the recurrent nerve, leading to laryngeal spasm or paraly- 
sis. Dyspnoea may occur with change of posture (Leube) and is 
paroxysmal; it is at times more or less urgent, or may sometimes sub- 
side entirely. 

3. Cough. — Cough is frequent, but is one of the least distinctive 
features. Tt results from pressure on the air passages, vagus irritation, 
bronchitis, or laryngeal involvement. It is often unproductive. Like 



ANEURYSM 473 

all other eccentric pressure symptoms, it varies with the size and 
direction of the aneurysm; it is paroxysmal (Morgagni) and is prone 
to appear or disappear hand in hand with the pain and dyspnoea. 

4. Difficult Swallowing. — Dysphagia is relatively infrequent. It 
results from direct compression or from pressure on the recurrent laryn- 
geal nerve, inducing oesophageal spasm. It occurs particularly in low 
aneurysms of the " recurrent type" (v. i. Larynx) and may produce 
distinct pulsations in a water tube introduced into the oesophagus. , One 
of the earliest aneurysms reported by Stokes was the size of an egg, and 
produced pain, dysphagia, and compression of the left bronchus, with 
rupture into the latter. Aneurysm may be confused with carcinoma 
of the oesophagus. Traube described a case of obstruction of the sub- 
clavian artery and compression of the left recurrent laryngeal nerve 
in which aneurysm was suspected; but the autopsy revealed carci- 
noma of the oesophagus embracing in its regional invasion the left sub- 
clavian artery and the recurrent laryngeal nerve. Dysphagia may be 
intermittent or present only when the patient is in one posture. Its 
infrequency is explained by the ready lateral luxation of the oesopha- 
gus ; dysphagia is most often due to adhesions between the aneurysm 
and the oesophagus. The danger of sounding the oesophagus is well 
known, for distressing lethal hemorrhages have occurred in the physi- 
cian's consultation room. 

5. Compression of the Vagus. — Vagus compression results in 
asthma, laryngeal spasm, vomiting, stenocardiac attacks, hiccough, 
and pulmonary symptoms. 

The Physical Signs of Aneurysm. — 1. Inspection. — Stokes described 
two areas of pulsation in the chest, each distinct "like two separate 
hearts.' 3 This is most significant when the cardiac impulse is the 
weaker. Inspection is most advantageously made with the eye just be- 
low the level of the shoulder and near the chest. The typical expansile 
pulsation is best detected in superficial thin-walled aneurysmata in the 
ascending arch, or in those presenting in the jugulum. Pulsation is less 
a question of the size than of the location of an aneurysm, and therefore 
visible pulsation may be absent even in the largest varieties, for deeply 
situated aneurysms give diffuse or no pulsation, or the pulsation appears 
only during expiration. Throbbing over the aorta is least important 
when there is also marked arterial pulsation (aortic regurgitation). 
The pulsation must be expansile to render the diagnosis absolutely 
sure, though at autopsy the author saw one case which presented clinic- 
ally an expanding throbbing aorta and dulness over the arch which 
was due to an enormous mass of callous connective tissue involving the 
pleura and pericardium. Another instance of a truly expansile pulsa- 
tion low down in the left side of the chest as well as near the spine was 
one observed in pernicious anaemia; the hands which had been placed 
over it were lifted widely apart, and the pulsation was seen at a distance 
of forty feet; the autopsy revealed no aneurysm. Pulsation lent to a 
tumor, a collapsed lung, the liver, or a pleural exudate, can usually be 
distinguished without difficulty. 



474 DISEASES OF THE CIRCULATION 

2. Palpation. — Pulsation is felt slightly later than the heart shock; 
this interval is more obvious the slower the heart rate becomes. 
The expansile character of the pulsation is sometimes more easily 
detected by the fingers than by the eye. Palpation may reveal remittent 
tension of the sac, tenderness on deeper pressure, resistance caused by 
thick lamellated thrombi, and, in rare cases, elasticity or fluctuation of 
the tumor during the diastole. Pulsation in a deeply situated aneurysm 
is best elicited by placing one hand anteriorly and the other posteriorly 
on the chest. A thrill may be felt which is most commonly systolic. 
A diastolic shock sometimes occurs in the jugulum and over the aortic 
area (Lancisi), and this is not due to recoil from the aortic valves, but 
to retraction of the hypertrophic aorta lying between the heart and the 
aneurysm (Rosenbach). It is possibly due to the retraction of the 
vessel wall. 

3. Percussion. — Dulness (Walshe) is an important finding only 
when it is present on either side of the sternum, but not when confined 
to the sternum. Dulness may be detected in the left interscapular 
region, though in this case percussion is less valuable, because of the 
thickness of the chest walls. Aneurysms are often obscured by an 
emphysema, and they may grow from their deep origin into the lung 
substance. The dulness may so merge with that of the spine, heart, 
liver, or spleen, that no certain statement can be made. Dulness when 
once detected may cease or shift to another place, and this is an 
almost certain indication of aneurysm, though it may occur in cysts 
(B ram well). 

It is inexplicable that aneurysms often grow toward and press upon 
relatively unyielding structures, while the softer parts in their immediate 
vicinity, as the lungs, are less compressed (v. Schroetter). 

4. Auscultation. — Auscultation is sometimes wholly negative, even 
in large sacs — explained by thrombi in the sac, and weak heart action. 
Two clear tones are most frequently heard; the second tone, heard over a 
circumscribed area, is pathognomonic of aneurysm (v. Schroetter), and 
originates in the aneurysm itself; some writers attribute it to closure of 
the aortic cusps ; it is most often heard in aneurysms near the ascending 
arch. Two tones in the abdominal aorta are scarcely ever heard 
normally. A systolic murmur is frequent, and is usually blowing, 
roaring, or scraping; it is due to vibrations in the aortic wall, to en- 
trance or exit of blood from the aorta into the sac, to blood waves 
initiated by angles in the direction of the current, by thrombi, or more 
rarely by pressure of the sac upon the aorta itself. 

The less frequent diastolic murmur is most probably caused by 
(relative) aortic insufficiency, when the aneurysm lies in the first part of 
the aorta. It may be due to folds in the aorta, vibrations of clots, dila- 
tation of the left ventricle, or to dissection of the aneurysm into the sinus 
Valsalvae (Stokes, Marey). It is usually combined with a systolic mur- 
mur. A continuous murmur is rare. Of 132 cases (Sansom) in which 
the diagnosis was made, only 12 presented a systolic murmur, 25 gave 
systolic and diastolic murmurs, and in six, diastolic murmurs alone were 



ANEURYSM 475 

found. Douglas-Powell detected murmurs in about half of his cases 
of sacculated aneurysms. 

The Heart. — Its position varies with the size and location of the 
aneurysm, (a) Large aneurysms of the ascending aorta not only de- 
press it, but cause such axial rotation that the left lies lower than the 
right ventricle; aneurysm in this location may cause atrophy of the 
right ventricle from pressure. (6) Aneurysm of the under surface of 
the arch may dislocate the heart to the median line, (c) Aneurysm of 
the descending segment may flatten the heart against the chest wall 
(Neusser), thus simulating mitral regurgitation, (d) Secondary aneu- 
rysmatic outgrowths from the chief aneurysm complicate the physical 
fin dings; these growths sometimes attain incredible proportions and 
produce confusing symptoms, (e) In uncomplicated cases, myocardial 
alteration is entirely accidental (Stokes, Key, and Skoda), which contra- 
dicts the usual statement that dilatation of the vascular system induces 
hypertrophy. Failure of the heart to hypertrophy is explained by 
anaemia, arteriosclerosis, coronary disease, or compression of the 
pulmonary artery, thereby decreasing the flow of blood to the left 
heart and coronary arteries. Hypertrophy of the left ventricle bears 
an intimate relation to aortic leakage; it may in rare cases result from 
aneurysm involving the entire periphery of the aorta. Stokes states 
that the most violent aneurysmal pulsation he ever witnessed occurred 
with marked myocardial atrophy. Compression of the pulmonary ar- 
tery (early observed by Rindfleisch and Obermeier) may cause relative 
tricuspid regurgitation or pulmonary insufficiency (v. Schroetter). 

The symptoms of aneurysm are given in their entirety in Stokes's 
early observations. 

The Vessels. — The pulsus differ ens is very frequently physiological, 
due to slight irregularities in the size or branches of the radial vessels. 
When one radial is small, its fellow ulnar is often vicariously larger. 
Stokes explicitly stated that the right radial is normally larger than 
the left, whence if the right radial pulse is smaller, it means more than 
if the left were slightly smaller. A pulse may grow smaller and later 
return to its normal size; this is due to change in the size and the 
direction of the aneurysm. When the radials differ essentially in 
volume it is advisable to compare the brachials. Asymmetrical 
sphygmographic tracings may be due to other causes than aneurysm 
as atheroma, coagula, embolism, or reduction of the lumen of a vessel 
to a mere slit, perhaps by the dragging of the aneurysm or compression 
of the aorta or its branches by the sac itself; v. Schroetter instances a 
case in which the aorta was so compressed by a sac lying between it 
and the spine that abdominal pulsation and the femoral pulses were 
obliterated. Changes are observed most often in the carotid and sub- 
clavian vessels. The pulsus paradoxus and capillary pulsation may 
occur in large aneurysmatic sacs (Quincke). Retardation of the pulse 
occurs especially in fusiform aneurysms. The location of an aneurysm 
may sometimes be determined by regarding the vessels altered. If 
pressure is exerted upon the superior cava, dropsy of the upper portion 



476 



DISEASES OF THE CIRCULATION 



Fig. 30. 



of the body, of one or both arms, swelling of the face and of the tongue, 
sometimes exophthalmos and a "brawny" or "collar-like" distention 
of the neck occur. Obstruction above the azygos vein causes lividity 
and oedema which are confined to the head and arms; when it occurs 
below that vessel the chest is also congested. Obliteration of the 
innominate and azygos veins or the venae cavse may occur. Rupture 
into the superior cava is attended by cyanosis, and a continuous bruit 
like the bruit de diable is often present; in Ewart's case (not suspected 
during life) phlebotomy was performed, and bright-colored blood 
escaped in jets. The continuous murmur may also occur in cases 
of vascular sarcomata. 

The Respiratory Tract. — Tracheal tugging, described by Oliver and 
Cardarelli simultaneously, is elicited by lifting the larynx with the 

fingers; a tugging sensation in 
the trachea is then felt with 
each systole; this symptom oc- 
curs in cases of cardiac over- 
action, left ventricle hypertrophy, 
aneurysmata of the arch and of 
the innominate and carotid ves- 
sels, and in adhesions to the 
trachea. 

Tracheal pulsation is present 
in many cases of aneurysm and 
may be demonstrated by the 
laryngoscope. The examination 
should be made by direct sun- 
light, and the observer should 
sit before the standing patient. 
Tracheal pulsation also occurs 
in tumors which compress the 
trachea; it may also be physio- 
logical. Drummond has de- 
scribed a systolic murmur over 
the trachea. A short murmur, 
synchronous with the systole, 
can sometimes be heard when 
the patient breathes quietly with 
the mouth open. Schroetter, 

Dieulafoy's diagram of the region in which he de- SanSOm, and Others, describe it 
scribes his "recurrent type" of aneurysm; » ; 

posterior view. A, aorta, in contact with the as XSchek, and refer it tO 
trachea and left bronchus; L, larynx (seen „ , , 

from behind); p, left and p' , right vagus; r, propagation irom the trachea. 
left recurrent laryngeal nerve, passing under 7-, , 7 7 ; 

the aorta, and r', right recurrent, in relation Recurrent Laryngeal paralysis 

to the subclavian artery. was firgt d escr ibed by Morgagni 

or by even earlier observers. Todd was the first to note laryngeal 
muscular atrophy on the affected side; paralysis may exist when the 
larynx is anatomically intact. Unilateral paralysis with the cadaveric 
position of the vocal cords, in the absence of obvious cause, is quite 




ANEURYSM 



477 



Fig. 31. 



indicative of intrathoracic aneurysm or neoplasm, though it is also seen 
in cases of mitral stenosis. The cough is hoarse, and makes a clang- 
ing or brazen sound. It is a paralytic cough, i. e., an imperfect 
expiration which lacks forcible closure of the glottis observed in ordi- 
nary coughing efforts; it was called the bovine cough by Wyllie from 
the fact that cattle have no false cords whose closure is an important 
mechanism in coughing. The right recurrent laryngeal nerve, curving 
around the subclavian artery, does not enter the thorax, and is there- 
fore seldom involved; whereas the left recurrent nerve passes into 
the chest and curves between the aorta and left bronchus; Dieulafoy 
described a "recurrent type of aneurysm," which is usually small 
syphilitic in origin, often multiple, involves the left recurrent nerve, 
and causes spasm of the larynx. The spasm is due to recurrent Ian n~ 
geal irritation which contracts the posterior transverse arytenoid 
muscle and induces dyspnoea and inspiratory stridor. Irritation of 
other vagus branches induces spasmodic dysphagia, anginal pain, etc. 
Lung Symptoms. — Stenosis of the right bronchus is less frequent 
than that of the left, for the latter lies nearer the aortic arch. The 
lung moves less freely than normal; it suffers inspiratory retraction, 

and the breath sounds and fremitus 
are diminished. When a short note 
is elicited over an upper lobe (especi- 
ally the left) it may cause suspicion of 
an aneurysmal compression with re- 
laxation of the lung. It is common in 
the "recurrent type" of Dieulafoy. 

Rokitansky concluded that large 
aneurysms are almost never associated 
with pulmonary tuberculosis , a view 
disproven by Stokes, Fuller, Jaccoud, 
Herard, Cornil, Hanot, and Kartz. 
Tuberculosis may result from (a) 
trophic change, (6) compression of the 
pulmonary artery, or (c) decreased 
lung excursion. It is found in 13 per 
cent, of the cases of aneurysm. 

Bronchiectasis, bronchorrhoea, and 
suppuration of the lung, is well called 
"aneurysmal phthisis" by Osier. Pul- 
monary retraction is observed from com- 
pression, adhesive pleurisy or interstitial 

Dieulafoy— Multiple syphilitic aneurysms, pneumonia. Pleurisy With effusion 

may complicate and entirely obscure an 
aneurysm. Pulmonary gangrene occurs from compression of the aortic 
nutrient artery of the lung or stagnation of mucus. Gangrene of the 
bronchial mucous membrane also occurs. Gangrene may produce 
subcutaneous emphysema. Pulmonary hemorrhage may occur from 
gross rupture into a large tube, from mere granulations in a compressed 




478 DISEASES OF THE CIRCULATION 

tube, or from an aneurysm slowly leaking into the parenchyma of the 
lung. The hemorrhage may be fatal, premonitory, or continuous; it 
may be seen as flecks in the sputum, as rusty sputum (but more abun- 
dant, more frothy, and less viscid than in pneumonia), as prune-juice 
expectoration with alveolar epithelium (as seen in valvular disease), 
and as discharges of pure blood or more frequently of imperfectly 
coagulated blood. 

Sympathetic Symptoms. — The pupils are often involved; myosis 
results from sympathetic paralysis and mydriasis from sympathetic 
stimulation. It must be remembered that 7 per cent, of all persons 
have irregular pupils. Other sympathetic symptoms, as pallor or 
redness, and sweating, are infrequent. 

Diagnosis. — The clinical signs and symptoms are most variable 
(Stokes). The presence of an aneurysm should be suspected when 
marked pain or paroxysmal dyspnoea occur. Variability of physical 
signs is suggestive of aneurysm. 

Diagnosis of Location. — 1. Aneurysm of the ascending portion is 
called by Broadbent the " aneurysm of physical signs." The usual 
signs are most often observed in the first interspace to the right of the 
sternum, which is often eroded. Luxation of the heart to the left, 
slowing of both radials, right recurrent paralysis, compression of the 
superior vena cava and of the pulmonary artery with hypertrophy 
of the right ventricle, dyspnoea and phthisis occur. Anginal or other 
cardiac symptoms frequently occur (Gairdner), and the aneurysm, 
though small, is usually rapidly fatal from rupture into the pericar- 
dium, pleura, upper cava, or heart-chambers. Aneurysms just above 
the valves tend to grow downward because of the reflux of blood from 
the aorta whereas those located higher grow upward, because of 
impact of blood from the left ventricle. Sympathetic involvement is 
common. 

2. In the arch, the " aneurysm of symptoms" is observed with 
left recurrent paralysis or spasm, stridor, pulsation in the jugulum, 
unusual prominence or luxation of the sternal ends of the clavicles, 
prominence of the subclavian arteries, dulness to the left of the ster- 
num, myosis, slowing or lessening of the left radial pulse, compres- 
sion of veins particularly the left innominate, of the trachea, thoracic 
duct, sympathetic ganglia, bronchi and left upper lobe, and disturb- 
ance in the brain circulation (hemiplegia) when the carotid artery is 
occluded. These aneurysms usually grow backward. 

3. In the descending segment, the "aneurysm of latency" is most 
often encountered. If there are symptoms, pulsation in the left inter- 
scapular region, slowing of the femoral pulse, pressure on the azygos 
or hemiazygos, pressure on the spine with erosion and tenderness to 
touch, intercostal neuralgia (sometimes with recurrent attacks of herpes 
zoster), stenosis of the left bronchus or oesophagus, pressure upon 
the heart forcing it against the sternum, and increased heart-rate 
from plexus pressure, are present. The #-rays alone may be able to 
detect aneurysms lodged in the lung substance. 



ANEURYSM 479 

Differentiation. — Differentiation from solid tumors is determined by 
their propagated non-expansile pulsation, their more rapid develop- 
ment, leukocytosis, and cachexia. In aneurysm the lymph glands 
are rarely enlarged either from lymph stasis or from inflammation; 
adenopathy is frequent in mediastinal tumor, and continued increase 
is directly indicative of neoplasm. Pain, recurrent paralysis and 
dysphagia are common to all tumors, both aneurysmatic and neo- 
plastic. Venous ectasia is more common in tumor. A few rare 
instances of coincidence of tumor and aneurysm are observed. The 
pulsation in carcinoma is rarely associated with a diastolic "back 
stroke," which is frequent in aneurysm. An unequal pulse indicates 
aneurysm or atheroma. The bruit in tumor is usually systolic, but 
murmurs are frequently absent in aneurysm. Tugging is present in 
both but more common in the latter. Signs of aortic atheroma argue 
in favor of aneurysm. Aneurysm runs a much more protracted course 
than tumors. Exploratory puncture and diagnosis ex juvantibus with 
iodide are of differential importance. 

Other causes for pulsation, such as a dynamic throbbing (aortic 
regurgitation), throbbing in acute aortitis, pulsation in an aorta dis- 
located from kyphosis, and pulsation in pneumonia (Graves) or in 
tumor of the lung or pleura, are usually differentiated when all symp- 
toms and signs are carefully considered. In pulsating empyema the 
dulness is usually low in the chest and largely left-sided; puncture 
reveals the presence of pus and stops the pulsation. 

Prognosis. — Recovery is rare, though spontaneous cure is possible 
by organization and calcification of thrombi in the sac or by its inflam- 
mation. Sometimes one aneurysm obliterates another. The course 
usually lasts more than a year. Patients have been known to live 
and work hard ten or twenty years. The author has watched for 
twelve years a blacksmith who has worked though he had an aneurysm 
of the ascending aorta, which was as large as his fist, and which pro- 
truded beyond the ribs. The size of the sac is of no prognostic value. 
Those of the small "recurrent type" are most dangerous, and large 
ones may be protected by connective tissue. Arteriosclerosis is prog- 
nostically unfavorable. 

Mechanism of Death. — (a) Rupture occurs in 75 per cent, of cases: 
20 per cent, into the left and 13 per cent, into the right pleura; 16 
per cent, into the left bronchus; 12 per cent, into the pericardium; 
9 per cent, into the left lung; 6 per cent, externally; 5 per cent, into 
the oesophagus; 4 per cent, into the trachea; (b) suffocation; (c) 
marasmus, especially in large aneurysms; (d) intercurrent disease; 
(e) embolism; and (/) brain lesions, are also immediate causes of 
death. Hemorrhage usually shortens the course, but in one case 
rupture into the bronchus occurred five years before death. Another 
patient suffered external rupture of the sac; he collected the blood 
in a basin and though he fainted from the hemorrhage he lived four 
months, only to die of typhus fever. Stokes described an instance of 
external rupture in which the presence of mind of the nurse, in stuffing 



480 DISEASES OF THE CIRCULATION 

ing some cloth into the sac, kept the patient alive for a considerable 
time. 

Treatment. — 1. The Tujnell treatment of rest, low diet, and 
limited fluid is the result of the methods used by Morgagni, Albertini, 
Valsalva and Bellingham, without the venesection recommended by 
Valsalva. Absolute mental and physical rest is required for several 
months, and food should be reduced to the minimum. The heart 
action and blood pressure are greatly lessened. The treatment is of 
value only in cases of sacs with small necks. Active individuals will 
not tolerate this method. Relative quietness, and moderation in every 
phase of life must then be insisted upon. Ergotin, hypodermatically, 
has little effect. Tr. aconite tt# i to iv may relieve the throbbing. 

2. The iodides have been given prominence by Balfour, though 
they were used first by Bouillaud and later by Graves, Nelaton, and 
others. It is not clear how they operate. They are of equal value in 
syphilitic and non-syphilitic cases. They increase the secretions but 
do not inspissate the blood. It is questionable from the experimental 
standpoint whether arterial tension and dilatation of the sac are 
lessened. Possibly the sac wall is thickened or clotting is facilitated. 
However, it is certain that pain is alleviated. Ten to twenty grains 
are given at a dose as in arteriosclerosis. The dose is lessened if the 
pulse rate increases. Aside from relief of pain, the iodides are useless 
in large aneurysms with wide communications or in fusiform varieties. 

3. Cold applications may relieve pain when the sac is near the 
surface. Supports may relieve the pain and protect against rupture. 
Calcium chloride in doses up to ten or fifteen grains has been used to 
promote coagulation, but apparently without effect. 

4. Gelatin injections (1 or 2 per cent, solution) are recommended 
by Lancereaux to produce coagulation in the sac. It cannot be said 
that the results are convincing. Gelatin has been used for centuries 
in China and Japan to aid coagulation. There is danger of embolism 
and 23 deaths from tetanus are reported by Dieulafoy, 1903. 

5. Electrolysis, introduction of fine wire, compression and surgical 
intervention have given discouraging results. A few cases of recovery 
are reported but one cannot help comparing their small number with 
the probably equal number of spontaneous recoveries (Boerger, in 
1906, compiled 19 cases of dissecting aneurysms of the aorta which 
recovered). Fatal thrombosis may follow what in a lesser degree of 
thrombosis might have been beneficial. Total embolism of the aorta 
may also occur. 

6. Dyspn&a is treated as in cardiac disease. Venesection may 
afford temporary relief, and morphine is finally indicated. Tracheot- 
omy may be necessary in laryngeal spasm (reflex recurrent irritation) 
but the actual compression by the sac is usually too low for operative 
interference. Digitalis is at all times contra-indicated. 



ABDOMINAL ANEURYSM 481 



Abdominal Aneurysm. 

This type constitutes 5 per cent, of aneurysms of the aorta. Over 
two-thirds occur in the upper part of the abdomen and 40 per cent, 
either at or above the cceliac axis. The average size is that of an orange 
and the tumor develops from the anterior surface of the vessel, less 
frequently from its lateral or posterior wall, and grows downward. 
Most of them are false aneurysms. 

Symptoms and Signs. — Four per cent, of abdominal aneurysms are 
latent clinically; a good sized sac may be hidden under the arch of 
the diaphragm. Pain is usual, and is constant and boring, or paroxys- 
mal. It may become less severe after hemorrhage from rupture. 
Relief is sometimes obtained by lying on the stomach. Indefinite 
symptoms are common in the stomach though they are less frequent 
than in the duodenum, where obstruction and hemorrhage may occur. 
Inspection does not show expansile pulsation and tumor in all cases. 
Palpation brings out the expansile pulsation and in some cases a 
thrill. Percussion may reveal dulness but the close relations to the 
liver, spine, kidneys and heart are prone to give indefinite findings. 
The diaphragm bounds the aneurysm above; the kidney to the left; 
the liver, pancreas and kidney to the right; and the stomach, pancreas 
and colon in front. The tissues about the sac thicken and produce 
adhesions. On auscultation, a systolic murmur (or two tones) is com- 
mon and may reach the spine or loins; a diastolic murmur is some- 
times heard. Rupture, diffusion by dissection, great thickening of the 
sac, and thrombi formation may easily obscure all auscultatory signs. 

Diagnosis. — 1. Compression Symptoms. — Compression symptoms, 
gastric and duodenal, have been mentioned. Abdominal aneurysm 
may be mistaken for gastric ulcer or cancer. The spine is eroded in 
10 per cent, of cases; lumbar neuralgia, lumbago muscular rheuma- 
tism, myelitis, Pott's disease, and spinal tumor may be simulated. 
Pulsation should be searched for along the spine. Symptoms in the 
renal region may suggest renal colic, kidney tumor, perinephritis or 
psoas abscess (fluctuating blood from rupture). The ureter may be 
compressed. Pressure on the splenic vein may produce much splenic 
enlargement. The heart is rarely compressed and dyspnoea is un- 
common. Retardation or absence of the femoral pulse may be of 
value in differentiation. 

2. Abdominal Pulsation. — " Instead of being your first, it should be 
your last idea that abdominal pulsation is due to aneurysm" (Jenner). 
Epigastric pulsation may be confused with hypertrophy of the right 
heart or pulsation of the liver. The greatest danger of error lies in 
diagnosticating as aneurysm the pulsation which is so often seen in 
acute hemorrhage, or especially in neurasthenic subjects, who com- 
plain of pain and throbbing and in whom thrills, systolic and, accord- 
ing to Rosenbach, even diastolic murmurs may be felt and heard, 
especially when atheroma is developing. Rosenbach especially em- 

'31 



482 DISEASES OF THE CIRCULATION 

phasizes the diagnostic importance of " intermittent dilatation of the 
aorta" which is frequently diagnosticated as aneurysm. The pulsation 
must be distinctly expansile (even then occasional errors are made) 
and a definite sac must be felt. Otherwise constant errors will be 
made. The dynamic pulsation of aortic regurgitation concerns the 
same points. 

3. Communicated Throbbing. — Communicated throbbing, lent to 
a tumor of the stomach lying on the aorta, may also be attended by 
systolic murmur but the differentiation is usually made with ease, 
except in certain soft neoplasms. Tumors are often felt to better 
advantage when the subject is in the genupectoral attitude; they are 
more movable, more often produce dilated veins, ascites, and peri- 
toneal friction. Aneurysm of the abdominal aorta or of its branches 
may, in exceptional cases, be movable. Stokes held that tumors 
developed upward and aneurysms downward. 

4. Aneurysm of the Branches of the Abdominal Aorta. — (a) Aneu- 
rysms of the celiac axis are difficult or impossible to distinguish and 
may occur with aneurysm of the main trunk. More than 20 cases are 
recorded. They are often traumatic or embolic (mycotic). (6) Super- 
ior (20 cases, Baccelli, 1904) or inferior mesenteric aneurysms are very 
uncommon; they occur most frequently in children, from sepsis, (c) 
Over 20 cases of splenic aneurysm are recorded. The spleen is often 
enlarged, (d) In the hepatic artery (35 cases, Grunert 1903) it is 
induced by acute infections (73 per cent.), trauma, embolism, or gall- 
stones ; 41 per cent, develop in the main trunk and 25 per cent, in its 
right branch; there is but one case in which it developed in the artery 
of the cystic duct. Pain, vomiting, hemorrhage, icterus, and large spleen 
have been noted: in 79 per cent, rupture occurred (in 10 cases into 
the peritoneum) ; they never pulsate, and in only one case was there 
a systolic murmur; Kehr operated on one case successfully, (e) Over 
10 cases of aneurysm of the coronary artery of the stomach are re- 
corded. (/) In the renal artery (26 cases, Skillern, 1906) aneurysm is 
rare. Three cases were successfully operated on. Von Schroetter 
found only 1 case in nearly 20,000 autopsies. 

Prognosis. — Death is usual and the clinical course averages one 
to three years. Rupture occurs in 66 to 75 per cent, of cases: 33 per 
cent, into the peritoneum; 16 per cent, into the pleura, though the crura 
of the diaphragm offers considerable resistance; 7 per cent, into the 
duodenum; and 7 per cent, into the retroperitoneal tissue. Death does 
not necessarily nor at once follow rupture even into the peritoneum. 

Treatment. — Treatment is as in the thoracic type. From its acces- 
sibility, operative procedures are more common and somewhat more 
successful. Continued compression of the aorta has benefited cases 
of aneurysm located low in the abdomen 



AORTITIS AND ARTERITIS 483 



ACUTE AORTITIS AND ARTERITIS, 

These are rare lesions, occurring in the aorta as part of a sepsis, 
benignant or malignant endocarditis, or in the peripheral vessels after 
influenza or other infections. Acute aortitis was often confused with 
chronic atheroma, acute arteritis, and with organizing thrombi in the 
arteries. Syphilis (q. v.) is a factor in aortitis, of which the symptoms 
are retrosternal burning, actual anginal pain, dyspnoea, anxiety, and 
acute dilatation of the arch without violent throbbing of its branches. 
The diagnosis is uncertain and the treatment symptomatic. 

Periarteritis nodosa was first described by Kussmaul and Maier 
and is called "arteritis proliferans nodosa" by Fletcher. This is a 
rare affection of which Verse* in 1905 could find but 20 published 
cases; it consists of localized proliferation and round cell infiltration 
of the intima with its rupture through the other coats, and leads to 
thrombosis or aneurysm. It is probably an infection. It occurs largely 
in men between twenty and thirty-five years of age; one case occurred 
in an infant three months old. The nodes are seen in the vessels of 
the muscles, heart, kidney, intestines, and skin ; they produce hydrops, 
nephritis, dyspepsia, alimentary hemorrhage, epigastric pain, low 
temperature, and a rapid pulse. The affection is fatal within six to 
twelve weeks, and treatment is purely symptomatic. In one-quarter 
of the cases there were syphilitic antecedents and Schmorl saw one 
cure with the use of mercury. 



[RUPTURE OF THE AORTA. 

Rupture of the aorta may be traumatic or the result of severe strain, 
endarteritis, or narrowing of the vessel. Tolot and Sarvonat (1904) 
collected but six cases of rupture of a sound aorta. All coats may be 
ruptured and this usually occurs in a transverse direction. If the rup- 
ture is partial, a dissecting aneurysm results which may burrow even 
to the popliteal arteries. It most often occurs in the first segment 
whence hsemopericardium results. Rupture into the lung, medias- 
tinum or retroperitoneal connective tissue may occur. The symp- 
toms are sudden pain, a sense of "something ruptured," and the signs 
of hemorrhage; sudden death usually occurs, though prolongation of 
life for from one to eleven years has been recorded in cases of dis- 
secting aneurysm. 

Embolism of the aorta has a close relation to thrombosis, being due 
to impaction of atheromatous plaques, tumor tissue, echinococcus 
cysts, endocarditic plugs or ordinary thrombi. It is very uncommon. 
Sudden death results if the site is in the first part of the vessel. If 
it occurs near the division of the iliacs, collateral circulation is possible. 
There are pain and stiffness in the legs, sensory disturbances, paresis 
and contractures from anaemia of the spinal cord. The femoral pul- 



484 DISEASES OF THE CIRCULATION 

sation is absent. The clot may back up toward the heart or it may 
resorb. The bladder and rectum are disturbed. Hemorrhage from 
the stomach, bowels and kidneys has been observed. The prognosis 
is bad, and the treatment is symptomatic. 

Thrombosis usually results from several coincident causes, as acute 
infections, weak heart, aneurysm, atheroma, or compression. Most 
cases occur in the transverse arch between the left carotid and sub- 
clavian vessels or in the abdominal aorta at its point of division. The 
pain, paraplegia, or anaesthesia produced are sometimes confused with 
spinal cord disease. It may be sudden; if gradual, collateral cir- 
culation may be established. 



SECTION III. 



DISEASES OF THE RESPIRATORY TRACT 



DISEASES OF THE NOSE. 

(A). ACUTE RHINITIS, CORYZA. 

Definition.— An acute, probably infective nasal inflammation. 

Etiology. — (a) It is an independent infection, sometimes epidemic 
and popularly held as contagious; it occurs oftenest in the spring 
and fall and is promoted by variations in temperature. Cold is 
probably only a predisposing factor; various bacteria are held causa- 
tive, but Thompson and Hewlitt have shown that 84 per cent, of cul- 
tures are negative. (6) It is a concomitant of various infections, 
notably of influenza, measles, pertussis, glanders, syphilis, etc. (c) 
Toxic factors, as iodides, bromides, ipecac dust, digitalin, dust, 
chemicals, etc., may cause coryza. (d) Local disease, as chronic 
catarrh, polyps, ulceration, etc., and possibly gout, are predisposing 
factors. 

Symptoms. — The initial symptoms are malaise, depression, anorexia 
chilliness, fever of 101° to 102°, pains in the limbs, and sometimes, 
in the young, delirium and convulsions. The mucosa is dry, reddened, 
burning, painful, swollen and obstructed. There is repeated sneezing 
and anosmia. Herpes is common. There follows a clear, watery, 
nasal discharge (coryza) for one or two days, which subsides at night 
and recurs in the morning; within two days it becomes thickened 
and purulent. Extension may occur to the eyes, frontal sinus, antrum 
of Highmore, ear by the Eustachian tube, or to the pharynx or larynx. 
In infants nasal occlusion prevents nursing and may cause dyspnoea 
or suffocation, because the tongue lies high in the mouth near the 

4S5 



486 DISEASES OF THE RESPIRATORY TRACT 

palate. Acute rhinitis lasts one-half to one week and is seldom con- 
fused except with incipient measles. 

Treatment. — At the very onset lavage with simple hot water is 
often sufficient; DobelFs solution (sod. borat and sod. bicarb, aa 5ij- 
ac. carbolici 5 SS to water 5x), diluted freely to avoid irritation, is bene- 
ficial; adrenalin solution 1 to 1,000 is excellent (excessive applica- 
tion of adrenalin may induce oedema of the throat and epiglottis). 
A cocaine solution (the plain alkaloid gr. j to albolene gj) relieves 
turgescence and frontal pain, but is a dangerous remedy to give into 
the patient's hands. Dover's powder gr. x, a saline aperient and a 
hot bath at the onset, usually give relief, specially when followed 

Extr. belladonnae gr. iiss. 

Fluidextr. aconiti tt£x. 

Phenacetini gr. xv. 

Camphoree monobrom gr. xv. 

M. et ft. capsulse x. 
S.— One capsule every hour for five or six doses. 

Drugs are often of little use unless the patient remains in bed to relieve 
internal congestion and to avoid extension or recurrence. Salicylates 
mitigate the frontal pain. Cool baths or rubs aid in averting recur- 
rent attacks. 

(B). HAY FEVER. 

Catarrhus aestivus, or summer catarrh, was first described by Bos- 
tock (1819). Morill Wyman first described the "June" or "rose 
cold." 

Etiology. — Its etiology is not known, but the disease has long been 
associated with the pollen of various plants and grains. Dunbar be- 
lieves that it is toxic, resulting from albumoses in the pollen. It pre- 
vails especially in England and the United States, develops in persons 
between fifteen and thirty years of age, and occurs twice as frequently in 
males as in females. It is more common in the upper educated classes, 
and perhaps in gouty individuals; it is most prevalent in the warm 
months, and in cities. Three special factors are noted: (a) A predis- 
position, either in the family in the form of nervous instability or other 
systemic tendency. (6) An irritability or other nasal abnormality, as 
undue nasal turgescence, or irritability to dust, smells, etc., hyper- 
esthesia of the inferior turbinates, polyps, or septal irregularities; 
Austin Flint became asthmatic from sleeping on feather pillows, (c) 
The exciting cause, or irritant, as pollen, dust, sudden change of tem- 
perature, and apparently in some cases mental excitement. Strepto- 
cocci have been sometimes found in the nasal secretion. 

Symptoms. — The onset is that of the vulgar coryza, but the disease 
is attended by more constitutional reaction and greater depression. 
Injection of the eyes with lachrymation and photophobia usually accom- 
panies or precedes the coryza. The throat, larynx, and bronchi are 



HAY FEVER 487 

dry and burning. Moderate fever, 100° to 101°, is fairly common. 
There is pain over the frontal sinuses and sometimes over the temporal 
and occipital regions. The nasal vessels are congested, and the nose 
itself becomes swollen and injected, resembling closely the alcoholic 
facies. In many cases cough develops; this is frequently followed by 
asthmatic seizures which simulate bronchial asthma. Recurrences are 
usual and attacks of coryza may alternate with asthmatic paroxysms. 
With the first frost the affection stops, as if by magic. The outlook 
is good as to life, for only isolated instances of death from asthma are 
recorded; as to recovery, the outlook is much less favorable. 

Treatment. — (a) Prophylactic treatment; cauterization of irritable, 
congested or hypertrophic areas, and correction of polypoid or other 
abnormalities cure some cases and alleviate suffering in others. (6) 
Nasal treatment; much relief may be given, when curative measures 
fail, by nasal douches, by painting or irrigating the nose with 1 to 
1,000 adrenalin and astringent solutions; suprarenal extract in doses 
of gr. ij to v has been recently used internally, as has nearly every 
drug in the Pharmacopoeia, (c) The general physiological resistance 
is increased by fresh air, by cool rubs, and by tonics and nervines. 
(d) Change of climate is advisable before the date on which, with 
certain* regularity, hay fever appears; a sojourn at the sea-side, in 
Northern Michigan, in Canada and especially in a high altitude, often 
greatly relieves or sometimes wholly checks the symptoms, (e) Asthma 
(v. Bronchial Asthma). (/) Dunbar's serum, patented as pollantin, is 
used in the nose (not hypodermatically) every morning, as a powder. 
Lubbert (1904) in 505 cases claims that 59 per cent, recovered, 28 
per cent, were benefited, and 13 per cent, were unaffected. 



(C). CHRONIC RHINITIS. 

Chronic nasal catarrh properly comes under the care of the special- 
ist, but minor cases are treated by the practitioner; some are due to 
scrofula, syphilis, ansemia or to other constitutional causes. Chronic 
catarrh may develop from repeated acute attacks, or may be chronic 
from the onset. 

The Hypertrophic Form. — The nasal mucosa is red, swollen, spongy, 
and is covered with thick, gray-yellow secretion which may dessicate 
and sometimes form the basis of rhinoliths. Microscopically, the 
bloodvessels are wide and are surrounded by round cells, and the 
submucosa is thickened. The nasal obstruction necessitates oral 
breathing, partially nasal speech, obtunded taste and smell, and 
produces an elevation of the hard palate and a peculiar facial expres- 
sion. The secretion is usually thick, yellow and purulent, rarely thin 
and abundant (rhinorrhcea). This type is often associated with 
adenoids and follicular hyperplasia in the pharynx. The lachrymal 
duct may be obstructed, and Eustachian occlusion may induce perma- 
nent deafness; laryngitis, bronchitis, bronchial asthma, polyps, and 



488 DISEASES OF THE RESPIRATORY TRACT 

sinus disease are not infrequent complications. Nasal disease may be 
the cause of blepharospasm or other facial spasms, limitation of the 
field of vision, vertigo, and mental depression; and even psychoses are 
attributed to nasal reflexes. Fliess attributes many dysmenorrheas to 
chronic rhinitis. In its treatment possible constitutional factors, as 
anaemia, syphilis or scrofula, are to be considered. Douches of car- 
bolic acid, insufflations of equal parts of alum and calomel, and cauter- 
ization by the galvanic cautery or by chromic acid, are indicated. 
Douches should be given under low pressure, lest fluid reach the middle 
ear. 

The Atrophic Form. — It is disputed whether this form begins as 
an atrophic process or results from hypertrophic disease. It is more 
frequent in females and usually begins early in life. The mucosa is 
pale and dry, its epithelium is lost or has suffered marked metaplasia, 
the erectile tissue wastes, the nasal passages are unduly roomy and 
there is but little secretion, which dries in the nose and emits a most 
offensive odor (pzaena). Its actual cause is not determined. Various 
of the common microorganisms have been found, but the Bacillus 
feetidus, Bacillus mucosus and Bacillus fluorescens liquefaciens are 
believed to be causative factors. Grosheintz and Meiser have noted 
its association with a widening of the face in 33 per cent, of cases. 
Its sequences are similar to those of the hypertrophic variety. 

Treatment. — The results of treatment are not satisfactory. Douches 
of a 1 per cent, permanganate of potash solution, iodoform insufflations, 
massage with iodine one part, potas. iodide 10, and glycerine 100 
parts, and packing with gauze soaked in balsam of Peru are usually 
employed. Paraffin injections beneath the mucous membrane have 
lately been recommended to restore the normal lumen of the nasal 
passages. 

(D). RHINITIS FIBRINOSA. 

Rhinitis fibrinosa has been spoken of in connection with nasal diph- 
theria, to which it is most often due. It may result from streptococcus 
and staphylococcus infection; it is observed in measles, scarlatina, 
pneumonia, and typhoid, and it also occurs as an independent lesion. 
Irrigation with 1 per cent, carbolic acid or 1 to 1,000 sublimate solu- 
tion is usually efficacious. Antitoxin is indicated in infection by the 
Klebs-Loeffler bacillus. 

(E). EPISTAXIS. 

Epistaxis is a symptom only. Its causes may be grouped as follows : 
(a) Local nasal lesions, trauma, chronic and acute catarrh, picking 
of the nose, foreign bodies, ulcerations (simple, tuberculous, syphilitic, 
carcinomatous), and angioma. Osier reports cases of epistaxis asso- 
ciated with telangiectasis of the skin and nasal mucosa, (b) Hyper- 
emia, either venous as in cardiac, respiratory and other obstructive 



ACUTE CATARRHAL LARYNGITIS 489 

lesions, or arterial as in hypertrophy of the left ventricle caused by 
aortic leakage, and as in interstitial nephritis, atheroma, apoplectic 
habitus, and gout. Some cases are seemingly vicarious to suppressed 
menstruation or hemorrhoidal bleeding, (c) Acute infections, prin- 
cipally typhoid, less frequently the others, (d) Hemorrhagic diseases, 
as pernicious anaemia, chlorosis, leukaemia, pseudoleukemia, scurvy, 
haemophilia, Werlhof s disease and cachexias, (e) Other conditions, 
as liver cirrhosis, pregnancy, icterus, diabetes, weakly constitution, 
and puberty; baloon ascensions or high altitudes are also causative 
factors. 

The most frequent point of hemorrhage is the lower anterior part 
of the cartilaginous septum. The symptoms are chiefly the local 
hemorrhage from the anterior nares, but occasionally bleeding may 
occur further back in the nose, and, trickling into the pharynx, may 
simulate hemorrhage from the stomach when vomited, from the 
intestine when passed with the stool, or from the lung when coughed up. 

Occasionally urgent acute anaemia or even death may occur, espe- 
cially when there is " blood dissolution" as in blood diseases. 

Treatment. — The patient should be kept quiet, in the semi-erect 
posture. After douching the nose with hot or ice-cold water to which 
adrenalin 1 to 1,000 or some tr. ferri chloridi has been added, the 
nose should be tamponed by Bellocq's catheter, or in less serious 
cases the patient should be enjoined not to blow the nose, for this 
only dislodges the forming clot. Gelatin may be injected into the nose, 
besides being injected hypodermatically. Internal remedies, as ergotin, 
are very unsatisfactory. Erosions or ulcers may later be cauterized. 



DISEASES OF THE LARYNX. 

(A). ACUTE CATARRHAL LARYNGITIS. 

Etiology. — Though acute catarrhal laryngitis is observed at every 
age and in all climates, most cases occur in males between twenty 
and forty, and in cold, windy, changeable weather, (a) Cold is fre- 
quently an apparent factor, but probably operates only by lessening 
the resistance, and this occurs to a greater extent in delicate than 
in robust subjects; the bacteriology of these "rheumatic" cases is 
unknown but its occasionally epidemic prevalence is suggestive of an 
infection. (6) Acute laryngitis may complicate acute (or chronic) 
affections such as measles, scarlatina, pertussis, typhoid, hay fever or 
syphilis, tuberculosis, and lupus, (c) Extension may be caused per 
contiguitatem from the nose, pharynx or bronchi; oral breathing is a 



490 DISEASES OF THE RESPIRATORY TRACT 

somewhat predisposing factor, (d) Chemical, thermal, or mechanical 
agents, as dust of all kinds, foreign bodies, trauma, overuse or abuse 
of the voice, alcoholism, inhalation of tobacco smoke, chlorine or 
bromine, and internal use of iodides are etiological factors, (e) 
Stasis from thoracic lesions or enlarged thyroid, local ulcerations in 
the larynx, nephritis, liver disease, chlorosis, and rhachitis are also 
causes. 

Symptoms. — A sudden onset, with fever, chill, rapid pulse or dys- 
pnoea is seldom observed. The local symptoms are a sense of rawness 
or tickling, dry, even spasmodic cough, and moderate pain on breath- 
ing, as the larynx is hypersensitive; sometimes external tenderness or 
some dysphagia may occur, usually from coincident pharyngitis. After 
a day or so a thin, transparent, and slightly cellular sputum appears, 
which later becomes purulent, yellow or in very rare cases, hemor- 
rhagic. Some cases void no sputum (laryngitis sicca). The voice 
becomes hoarse or is wholly lost. The laryngoscope reveals diffuse 
or circumscribed redness, viscid mucus, some swelling, and occasion- 
ally epithelial erosions. The false cords are often swollen. The true 
cords lose their smooth, glistening appearance and become injected 
and uneven, so that their even coaptation is hindered. The swollen 
mucosa may get between the cords, and their infiltrated muscles are 
often paretic. The acute symptoms last for a day or two and the 
catarrh remains about a week longer. 

Diagnosis. — Diagnosis is usually easy; nervous aphonia and cordal 
paralysis are distinguished by means of the mirror (see Vagus Dis- 
ease, under Nervous System). 

Treatment. — Prophylaxis covers the etiological factors; alcohol 
and tobacco should be forbidden. The general resistance is increased 
by cold rubbings, douches or baths, and exposure, locally, of the neck; 
mufflers should be avoided and cold water should be applied over 
the larynx. The voice must be used carefully and the nose, uvula 
and pharynx should be examined for predisposing lesions. 

The therapy of the established lesion is as follows: At the onset 
sweating should be induced by hot drinks and by a hot bath; Dover's 
powder and quinine, each gr. x, or aconite, are indicated as in coryza; 
rest in bed is necessary. The voice must not be used. If the symp- 
toms persist, an ice-bag should be applied locally; codeine or morphine 
with bromides, and inhalations of moist air or steam should be given, 
as described under Acute Bronchitis. 

Heroin hydrochloratis gr. j. 

Terpene hydratis gr. xl. 

Ammonii chloridi 5ss. 

Extr. glycyrrhizae 5j- 

M. et ft. capsular xv. 
S. — One after meals. 

Painting the larynx with a 3 per cent, silver nitrate solution is recom- 
mended by some physicians and is condemned by others as promoting 
submucous extension. 



ACUTE CATARRHAL LARYNGITIS 491 

In children acute laryngitis is often attended by great swelling 
above and below the cords and by stenotic manifestations in the small, 
infantile larynx. The symptoms closely approach those of genuine 
croup (laryngeal diphtheria), from which it is distinguished as false 
croup, faux croup (Guersant) or laryngite striduleuse (Bretonneau). 
After an attack of mild laryngitis, coryza or sore throat, the child 
becomes restless and anxious, usually during the night when the 
secretion accumulates. Inspiratory dyspnoea develops, there is inspir- 
atory retraction of the interspaces and epigastrium, the accessory 
muscles of respiration come into play, cyanosis appears and asphyxia 
seems to be imminent. The paroxysm subsides, spontaneously or 
after an emetic has been given, but it occurs again on the next two 
or three nights. The catarrhal symptoms may last from three days to 
a week. Trousseau remarked that there is rarely the complete aphonia 
which is observed in laryngeal diphtheria. The diagnosis is made from 
the history of coryza; the absence of diphtheritic patches in the phar- 
ynx, for diphtheria is eminently a descending infection; the absence 
of diphtheria bacilli, found in diphtheria even when the throat seems 
normal; and the absence of severe constitutional reaction. Laryn- 
gismus stridulus (v. Vagus Nekve) is not attended by fever, laryngitis, 
or aphonia. The laryngoscope may reveal the simple cedematous laryn- 
gitis, but examination is notoriously difficult in easily frightened chil- 
dren. Treatment is the same as in acute laryngitis of adults; hot 
drinks, inhalation of steaming water and ipecac should be given to 
induce vomiting and evacuation of laryngeal secretion ; von Niemeyer 
awakened the patient at intervals and gave a hot drink to evacuate the 
mucus. Widerhofer also noted excellent results from washing away 
any pharyngeal mucus, which he considers causative of the attacks. 
The attendant should be prepared, in doubtful cases, for intubation 
or tracheotomy. 

Other acute forms are (a) laryngitis acuta nodosa, which is observed 
in acute rheumatism and which yields to salicylates, (b) Laryngitis 
fibrinosa, which is usually diphtheria, but which may be caused by a 
streptococcus infection in measles, scarlatina or other infections, and 
which sometimes results from inhalations of steam, or chlorine, (c) 
Laryngitis submucosa acuta invades the submucous tissues and is 
seropurulent. This rare affection may develop as an independent 
lesion, may follow a similar process in the pharynx, or may represent 
a septic localization. During invasion the symptoms are severe, with 
fever, rigor, delirium and other septic phenomena. The laryngoscope 
shows injection and yellow-white bulging areas of submucous suppura- 
tion which, without operation, almost invariably cause death by oedema 
of the larynx or by sepsis, for spontaneous rupture is exceptional. 
For treatment (a) an ice-bag should be placed over the larynx, mor- 
phine should be given for pain, and whisky for the sepsis; (b) incision 
of the foci is indicated; and (c) if necessary, intubation or tracheotomy 
should be performed. 



492 DISEASES OF THE RESPIRATORY TRACT 



(B). CHRONIC CATARRHAL LARYNGITIS. 

Etiology. — The etiology of this . type is practically identical with 
that of the acute form, of which it frequently follows repeated attacks ; 
it is often associated with or is dependent on pharyngitis or rhinitis. 

Symptoms. — The symptoms are those of the acute form, though 
less intense. Hoarseness alternates with fairly normal phonation. By 
the mirror there may be seen injection, darker than in the acute form, 
swelling, secretion, and sometimes stains from small hemorrhages. 
There are forms with no secretion (laryngitis sicca chronica); the 
secretion is rarely like that of ozsena, with glandular atrophy. In 
some forms granules appear, less from glandular hyperplasia than from 
proliferation of connective tissue (laryngitis granulosa). Erosions and 
rhagades may develop on the edges of the cords, or arytenoid carti- 
lages. Ulcers are most often syphilitic or tuberculous. 

Treatment. — Treatment of the cause and prophylactic measures are 
the same as in the acute form. Inhalations of 1 per cent, tannic acid 
or of 1 per cent, turpentine and sod. bicarbonate in solution; insuffla- 
tions of tannic acid, lead acetate and alum aa gr. i; and according 
to some physicians, painting the larynx every third day with a 2 to 
10 per cent, solution of silver nitrate with the aid of the laryngoscope, 
are valuable. Terpine hydrate gr. iij t. i. d. is often helpful. Cold 
water applied over the larynx, faradization, compressed air, and sea 
air may be beneficial. 

Other Chronic Forms. — Chorditis tuberosa occurs as small grayish 
nodes on the cordal edges at the junction of their anterior and middle 
thirds, especially in singers and in alcoholics (Stoerk) ; they are com- 
posed of fibrous and epithelial hypertrophy. Scarification and lactic 
acid are indicated (v. Tuberculosis). 

Pachydermia laryngis (Virchow) is an increase of the submucous 
tissue and transformed epithelium into which connective tissue grows; 
it is circumscribed or diffuse. Warty excrescences are common between 
the arytenoids, and the thick mucosa is sometimes umbilicated and 
may resemble cancer. Topical application of salicylic or lactic acid, 
iodine in glycerine, electrolysis and the cautery are indicated. Polyps 
may result from chronic laryngitis. 

Laryngitis hypertrophica inferior is a hyperplasia of the mucous 
and submucous tissue below the cords, and is identified by some 
clinicians with nasal rhinoscleroma, which is due to the extension of 
the rhinoscleroma bacillus from above downward. It may cause 
stenosis of the larynx, which the author saw in one of Kolisko's autop- 
sies. It is treated by scarification, dilitation, prolonged intubation, 
iodides, or, when extreme, by tracheotomy. 



(EDEMA OF THE LARYNX 493 



(C). (EDEMA OF THE LARYNX. 

(Edema laryngis is a more proper designation than oedema glottidis, 
as the vocal cords are very seldom involved. It is most marked where 
the submucous tissue abounds and is greatest therefore about the 
epiglottis and ary-epiglottidean folds; it may develop under the cords. 
It varies with its cause, and may be bilateral, unilateral, diffuse or 
circumscribed. According to Sestier, 70 per cent, of cases occur in 
males and 89 per cent, in those over fifteen years. 

Etiology. — There are three etiological forms besides some obscure 
cases, (a) Inflammatory wdema results from various inflammatory dis- 
eases of the larynx, submucous suppuration, or perichondritis; from 
typhoid, syphilitic, tuberculous or cancerous ulceration; from iodides; 
from trauma, surgical measures, thermic, chemical and allied causes; 
from extension from pharyngitis, parotitis, or cervical cellulitis; and 
from infections, as typhoid or measles. (b) Congestive and hydremic 
forms result from chronic heart and lung disease, from tumors and 
nephritis, in which it may antedate oedema elsewhere, or from cachec- 
tic conditions as carcinosis or amyloidosis, (c) Angioneurotic cedema^ 
as in R. S. Morris's fatal case, is the last type. 

Symptoms. — Symptoms appear with varying acuity, sometimes 
most suddenly, as in B right's disease, at other times more gradually but 
progressively, and again quite slowly. Hoarseness or aphonia, and a 
metallic cough are common. The chief sign is inspiratory dyspnwa, 
which characterizes nearly all forms of laryngeal stenosis. It is usually 
stridulous or wheezing; and is attended by retraction of the inter- 
spaces, cyanosis, up-and-down excursion of the larynx and ultimate 
suffocation. The mirror shows a pallid swelling in the parts enumer- 
ated, incision of which allows the escape of a clear serum. (Edema 
of the epiglottis and ary-epiglottidean folds may be felt with the finger 
if the mouth is held open and the tongue drawn forward, or it may be 
seen even without the mirror if the larynx is pushed up and the tongue 
deeply depressed. 

Treatment. — Treatment is urgent, irrespective of the cause, for the 
large mortality (75 per cent.) is due to delay until the patient's strength 
is exhausted. The placing of ice over the larynx, the swallowing of ice, 
drastic purgatives and painting the larynx with 10 per cent, silver 
solution are at best palliative. The cedematous tissue should be fully 
incised, and, in case this should fail, intubation or tracheotomy should 
be performed. 

(D). PERICHONDRITIS LARYNGIS. 

Purulent inflammation beneath the perichondrium of the cartilages 
of the larynx is very seldom primary, but nearly always results second- 
arily to various inflammations or ulcerations. Pus accumulates 
between the perichondrium and cartilage, most frequently the ante- 



494 DISEASES OF THE RESPIRATORY TRACT 

noid or cricoid, or less frequently the thyroid or epiglottic. It may 
burrow; the cartilage may become secondarily necrosed. Perichon- 
dritis laryngis most often develops in males between twenty and forty 
years of age. 

Symptoms. — Its symptoms are commonly obscured by the causal 
disease. The rare primary cases are the most acute. Well localized 
pain and tenderness are peculiarly significant. Dysphagia, especially 
from arytenoid involvement, is frequent, and even aphagia may result. 
Phonation is impaired by the fundamental disease, by cord paresis and 
muscular infiltration. The cervical glands sometimes tumefy. Stenosis 
and dyspnwa are present. The mirror discloses focal accumulation of 
pus, swelling, redness, oedema and perhaps fistulas which signify intra- 
laryngeal rupture. The probe may elicit tenderness or may scrape 
on eroded cartilage. The diagnosis from laryngitis and oedema is 
often impossible, or at best but probable unless definite pus pockets are 
seen. The outcome may be suddenly fatal from rapid oedema; pus and 
cartilage fragments may rupture, thus giving relief or perhaps oc- 
cluding the larynx; fistulse, internal or external, may remain, and 
may burrow to the mediastinum, or sepsis may follow; aspiration 
pneumonia is not uncommon, and if immediate recovery ensues, a 
distorted or stenosed larynx may remain. 

Treatment. — Treatment is similar to that of acute laryngitis; the 
pain should be relieved by opiates, but early incision under cocaine is 
necessary, and the physician should be prepared to perform trache- 
otomy or intubation. 

(E). ULCERATIONS AND NEOPLASMS OF THE LARYNX. 

The tuberculous and syphilitic ulcers have been considered. 
Superficial erosions may follow catarrh; deep ulcers result from sub- 
mucous suppuration or from perichondritis, pressure ulcers from 
foreign bodies or laryngeal "bed sores" (v. Typhoid); some clinicians 
consider the latter to be an ulceration analogous to intestinal ulcer- 
ation. There are also the specific ulcerations of leprosy, glanders, etc. 

Tumors include benign single or multiple papillomata located on the 
true cords (singer's nodes v.s.), fibromata, cysts, amyloid accretions, en- 
chondromata,lipomata, and the malignant tumors, of which carcinoma 
is far more frequent than sarcoma. Primary cancer develops slowly on 
the posterior third of the cords or in other locations, as an excrescence 
which gradually assumes a cauliflower appearance; the basis of the 
later ulceration is nodular and there is no scar formation (v. Syphilis, 
Larynx) ; hoarseness is an early symptom; all kinds of incipient tumors 
are frequently mistaken for laryngitis. Pain which may radiate to the 
ears or temples, cough, and dysphagia are constant in the advanced 
stage. Early operation, either intralaryngeal or by splitting the thy- 
roid, will alone afford relief; inoperable cases] must [necessarily be 
narcotized. 



ACUTE BRONCHITIS 495 

Nervous aphonia, the paralyses and spasms of the larynx are con- 
sidered under affections of the vagus nerve; syphilis and tuberculosis 
have already received consideration. 



DISEASES OF THE TRACHEA AND BRONCHI. 

The trachea is seldom involved alone. Tracheitis is frequent, with 
inflammation of the larynx and bronchi. Hemorrhage may result from 
diapedesis or from ruptured varices. Tuberculosis, syphilis and 
tumors are very infrequent. 

(A). ACUTE BRONCHITIS. 

Acute bronchitis is a most frequent primary or secondary disease, in 
some localities constituting 10 to 15 percent, of all diseases. It occurs 
most frequently in cold, dusty or variable weather; three-fourths of all 
cases occur between December and April. Its forms are (a) inflam- 
mation of the larger air tubes, bronchitis, tracheobronchitis or macro- 
bronchitis, and (6) inflammation of the smaller tubules, known as 
bronchiolitis, capillary bronchitis or microbronchitis, which in children 
is identical with bronchopneumonia (q. v.). 

Etiology. — (a) It is a symptom of various infections, as measles, 
pertussis, influenza and typhoid; it also occurs frequently in scarlatina, 
variola, malaria, pneumonia, diphtheria, erysipelas, syphilis, tuber- 
culosis, sepsis, glanders, actinomycosis, and anthrax. In these maladies 
bronchitis is secondary and results from the germs or their toxins, (b) 
It may result from the toxic effects of potassium iodide or bromide, 
tobacco, less often carbolic acid, cantharides, mercury and alcohol, 
which according to Hoffman, acts locally on the air passages, (c) 
Mechanical irritants are dust, and other foreign particles, as flour dust, 
particles of wool, metals, stone, etc., which exist in many factories; over- 
use or abuse of the voice is also a mechanical irritant, (d) Constitu- 
tional conditions, as obesity, nephritis, rhachitis, gout, scrofula, anaemia, 
diabetes, malnutrition and cachexia of various kinds, such as cancer, 
syphilis, or scurvy, are important etiological conditions, (e) Venous 
stasis in the lesser circuit favors bronchitis, by congesting the pulmo- 
nary veins, which empty chiefly into the vena cava superior and vena 
azygos; mitral lesions are the most important, but other valvular dis- 
ease, arteriosclerosis, scoliosis, abdominal tumors, ascites or pleurisy, 
all of which affect the diaphragmatic excursion, are possible factors. 
(/) Respiratory diseases, as pneumonia, tuberculosis, abscess or gan- 



496 DISEASES OF THE RESPIRATORY TRACT 

grene of the lung, asthma, bronchial stenosis, and bronchiectasis are 
usually associated with bronchitis. (g) Cold and bacteria are also 
etiological factors. It is disputed whether cold alone is an adequate 
factor without the cooperation of bacteria, but it at least plays a 
potent predisposing part. Even in cases of apparently primary bron- 
chitis, the pneumococcus, pyogenic cocci, Friedlander's pneumo- 
bacillus and other bacteria are found {v. $.). Pfeiffer's micrococcus 
catarrhal™ is found in 59 per cent, of cases (Ghon, Pfeiffer); it 
is larger than the staphylococcus and often occurs in pairs, (h) Age 
is a factor. Acute bronchitis may develop at any time of life, but is 
peculiarly frequent in the aged and in children between six months and 
three years old. 

Symptoms. — 1. Acute bronchitis of the larger tubes {macrobron- 
chitis or tracheobronchitis) begins (a) with some constitutional depres- 
sion, sometimes with fever and chilliness or in children even with 
marked toxemic symptoms. It often follows acute coryza or pharyn- 
gitis, (b) The local symptoms are substernal rawness or tickling; actual 
pain or tenderness over the sternum is mostly tracheal or muscular, for 
the bronchi have apparently no nerves for perception of pain. On in- 
spection of the trachea there is visible inflammation, redness, diffuse or 
circumscribed injection, submucous ecchymosis, swelling and laxness 
of the mucosa, and dryness, which is followed by the appearance of 
a viscid transparent glairy mucous secretion ; the mucous glands are 
often distended by globules of mucin which slightly resemble young 
tubercles; most of these findings are also noted in the bronchi in the 
rare cases which come to autopsy, but injection and redness largely 
disappear after death. Microscopically the cardinal signs of inflam- 
mation are found, such as paresis of the vessels, round cell emigra- 
tion, desquamation of the ciliated epithelium, and compensatory efforts 
at restoration by multiplication, (c) The cough is at first dry and un- 
productive and may remain so. Later a viscid, transparent sputum 
is raised, consisting almost wholly of mucin and very few white cells 
(sputum crudum). A day or two later the coughing efforts become less 
severe as the sputum grows more abundant and mucopurulent {sputum 
coctum) ; it contains polymorphonuclear and sometimes abundant 
eosinophilic leukocytes, epithelial cells showing myeloid degeneration, 
and rarely ciliary epithelium or hemorrhagic spots. Localized inflam- 
mation at the tracheal bifurcation causes special irritation (Nothna- 
gel). (d) The symptoms resulting from cough are disturbed sleep; 
hoarseness from forcible closure of the glottis in coughing efforts; 
pain in the side or at the diaphragmatic insertion, from unusual 
strain on the expiratory muscles during coughing ; venous stasis which 
induces headache, vertigo, swollen cervical veins, cyanosis and epis- 
taxis; mechanical sequences, as vomiting, involuntary urination, es- 
pecially in weak and old subjects; and in women, even abortion, 
uterine prolapse, or hernia may occur. (e) Physical findings are 
usually bilateral; unilateral signs, though possible, suggest other lesions, 
especially tuberculosis. Auscultation reveals rhonchi, which result 



ACUTE BRONCHITIS 497 

from swelling of the bronchial mucosa, from slight stenosis by bron- 
chial secretion and from air passing through or dislodging the secretion. 
The rhonchi at first are dry (r. sicci), and later moist (r. humidi). 
Over the large tubes these rales are sonorous, in the smaller tubules 
they are sibilant, and in both they vary acoustically. They may be 
heard simultaneously over the large and small passages, or success- 
ively, over the large and then over the small tubules. These rales, large 
and small, may be felt with the hand (mucous fremitus) or may be 
heard without the stethoscope. The breathing may be "cog-wheel," 
lengthened, slowed or sometimes increased by fever, but in quality it is 
only exaggerated or puerile, never bronchial. Percussion is wholly 
negative. Macrobronchitis lasts but a few days, possibly a little 
longer than a week. 

2. Microbronchitis or capillary bronchitis is essentially the same 
pathological process as macrobronchitis but will be considered under 
bronchopneumonia, because of its great tendency, especially in 
children, toward pulmonary inflammation. 

Treatment. — In the early stage a full hot bath may be given, followed 
by a hot alcoholic drink. A hot Turkish bath should never be taken, 
for exposure afterward is dangerous. Hot fomentations over the 
sternum are beneficial; a hot water bag or a large poultice may be 
applied over the sternum, but cold packs over the neck and chest are 
even more efficacious. Patients should always be kept in bed, for but 
few cases recover promptly without this treatment. A mild laxative 
should be given early. A drink or two of well diluted whisky is 
valuable. When the initial symptoms appear gr. x of Dover's 
powder should be given ; it not only relieves pain and coughing but also 
appears to inhibit or modify the inflammation; in children it should be 
given with great caution because of the frequently unequal mixture of 
its constituents, and the peculiar susceptibility of the youthful nervous 
system to narcotics; in the aged it should likewise be administered 
with care, because the kidneys in old persons excrete slowly, and cere- 
bral atheroma may induce sudden urgent symptoms, as psychical dis- 
turbance, Cheyne-Stokes breathing, and other basilar disturbances. 
The administration of opiates should be followed by some saline 
aperient. Muscular pain necessitates massage and administration of 
opiates. Other treatment is frequently superfluous, but if the symptoms 
and cough persist or if the initial symptoms are rather severe we ad- 
minister: 

Vini antimonii 5iv. 

Heroin hydrochloratis . . gr. iss. 

Vini ipecacuanha? 3 v. 

Syr. tolutani , q.s. ad §ij. 

M. et S. — One teaspoonful every three or four hours. The patient should be 
watched lest gastric symptoms appear. 



32 



498 DISEASES OF THE RESPIRATORY TRACT 

Potassii citratis 5iiss. 3j- 

Codeinae sulphatis . gr. iv. gr. j. 

Syrupi ipecacuanhse . . oiv. Biss. 

Succi limonis . . . . 5j. gss. 

Aquae q.s. ad gij. gij. 

M. et S. — One teaspoonful every two hours. The first column is the dosage for 
adults, the second for children. 

The fever rarely requires treatment; if high, aconite and belladonna 
may be given, as in coryza, but tepid sponging is more beneficial. A 
kettle should be kept boiling in the room to moisten the atmosphere, or 
a steam tent may be advisable as in croup (see Diphtheria). If the 
bronchitis lingers longer, the formulae given under chronic bronchitis 
will be useful. 

(B). CHRONIC BRONCHITIS. 

Etiology. — The etiology is essentially that of the acute type. Chronic 
bronchitis is more common in advanced life, and may develop slowly as 
a chronic process, or, more often, may follow repeated acute attacks. 
It may be manifest during the entire year, but most often develops on 
change of weather or in the cold season, as the " winter cough." 

Pathology. — The larger and medium sized bronchi are most in- 
volved. Their color is a gray red or brown; the bloodvessels are 
thickened, and the bronchi become thicker from extravasation of 
leukocytes and proliferation of the peribronchial connective tissue; 
the mucous membrane is sometimes hypertrophied, and even protrudes 
in polypoid and papillary excrescences, or is atrophied, and appears 
thin and pale like a serous membrane. Erosions are not common but 
are sometimes seen at the tracheal bifurcation, especially in the aged. 
Stagnation of secretion is common. The inner surface of the bronchi 
is at times reticular, due to the prominence and hyperplasia of some 
elastic fibers and the wasting and sinking of other elastic or muscular 
fibers. Emphysema and some interstitial fibrous overgrowth are 
frequently found at autopsy. 

Symptoms. — Fever and pain are absent, except in the frequent acute 
exacerbations. The usual intrinsic physical findings in chronic macro- 
bronchitis are large sonorous rales, and sibilant rales when acute 
exacerbations causeinvasionof the finer tubules. The cough varies with 
the intensity of the inflammation, with the amount and character of the 
secretion, or with changes in the weather. The sputum varies greatly, 
and upon its character is based the division into the following forms : 
(a) Dry bronchitis, the bronchitis sicca of Laennec,' which is seen in the 
aged and is almost always associated with emphysema; in this type 
the sputum is either wholly absent or is very scant and viscid, (b) 
Bronchorrhcea, in which the excessive bronchial secretion may be 
mucous, serous, or purulent ; in the serous form the secretion is thin 
and transparent, as in Laennec's case, in which two quarts were raised 
daily for twelve years; Struempell observed a serous bronchorrhcea 



CHRONIC BRONCHITIS 499 

resulting from enlarged peribronchial glands; the purulent form may 
be confused, on account of its abundant sputum, with bronchiec- 
tasis, lung abscess, or rupture of an empyema into the bronchi, 
(c) Putrid bronchitis, which has been described by Laennec, Andral and 
Traube. It may complicate chronic bronchitis but occurs more often 
with bronchiectasis, foreign intrabronchial bodies and tuberculosis; 
in this form the sputum stinks and is acidulous particularly when first 
voided. It consists of three layers ; the upper one is foamy, the middle 
layer is serous, and the lower one consists of granular gray-green or 
bluish sediment, in which are also the mycotic plugs of Dittrich (1850); 
these plugs contain various bacteria, leptothrix staining violet with 
iodine, strepto- and staphylococci, Bacillus coli and Bacillus putridus 
and sometimes monads. Bacilli which retain fuchsin after treatment with 
mineral acids (" acid-fast" bacilli) are found in putrid bronchitis and 
in gangrene of the lung. They closely resemble tubercle bacilli, though 
they are narrower, more pointed at their ends and do not give inocu- 
lation results. Fat and myelin droplets, fatty needles, leucin, and 
tyrosin are also present. The amount of sputum may even reach a 
pint. Fever is common, "drum stick" fingers may develop, and com- 
plications may follow, as lung induration, diphtheroid ulceration, 
gangrene, pleurisy, haemoptysis, cerebrospinal abscess, meningitis or 
pseudorheumatism. The fever frequently recurs, (d) Blood-stained 
sputum occurs particularly in the brown induration of the lungs, which 
is due to stasis (v. Cardiac Stasis). 

Chronic emphysema (v. i.) is an almost regular complication and is 
marked by its usual signs, such as a tympanitic percussion note, volum- 
inous lungs, prolonged and, on exertion, difficult expiration, weakened 
vesicular murmur, hypertrophy of the cervical muscles, swollen neck 
veins, signs of right heart hypertrophy and dilatation, and eventually 
tricuspid insufficiency, liver congestion, and oedema. 

Diagnosis. — The diagnosis is generally easy. Determination of its 
relation to tuberculosis and other causal features is most important. 
In every case chronic nephritis should be considered. 

Prognosis. — The prognosis depends on the etiological factors. Ab- 
solute recovery is most unlikely. 

Treatment. — 1. Prophylaxis. Causal affections require treatment. 
Woolen underwear should be worn to protect against sudden changes 
of temperature. 

2. Climate. — When feasible, a dry, warm, even climate is beneficial, 
as that of Florida, Southern California, New Mexico, the Carolinas, 
Egypt, and the Riviera. 

3. Cough.— Codein, morphine, creosote, cod-liver oil and otlier 
remedies are employed as in tuberculosis (q. v.). Amnion, carb. (v. 
Pneumonia) gr. iij. can be given with syr. seneg.se 5j; s t Y r - scilla? 5j is 
incompatible with amnion, carb. but may be combined with amnion, 
chlor. gr. v to x. 



500 DISEASES OF THE RESPIRATORY TRACT 

Ammonii chloridi 3iss. 

Misturse glycyrrhizse comp o'w. 

M. et S. — One teaspoonful after meals. 

The inistura glycyrrhizse comp. (Brown's mixture) contains twelve 
parts of paregoric, six parts of antimonial wine and three parts of sweet 
spirits of nitre, which enhance its sedative action. It may be given in 
doses of from one to four drams. If the heart is weak, it is contra- 
indicated because of the antimony it contains. In all cough prepa- 
rations, the stomach may become deranged by ammonium, syrups, 
etc. Chloroform is particularly valuable in paroxysmal unproductive 
coughs, which opiates may not alleviate because they dry up the 
secretion. 

Ammonii carbonatis 5j- 

Spiritus chloroformi 5iss. 

Syrupi senegse q.s. ad giij. 

M. et S. — One teaspoonful in hot water as indicated. 

Apomorphinae hydrochloridi gr. ss. 

Heroin hydrochlorat gr. j. 

Spiritus chloroformi oj- 

Aquae q.s. ad 5ij. 

M. et S. — One teaspoonful two or three times a day. 

Syr. scillse comp. also contains senega and tartar emetic and is given in 
doses of gtt. xx to xl. The antimony it contains may depress the heart. 
Terpin hydrate is excellent, gr. hi to v (x). t. i. d., given in capsules with 
equal amounts of benzoic acid. The balsams are even more efficacious, 
as ol. terebinthinee TT^ij. in milk (see formula for emulsion under 
Typhoid, Treatment of Tympany); ol. santali tt# x to xx in emul- 
sion is less likely to disturb the kidneys than is turpentine; balsamum 
Peruvianum 5ss or bals. tolutanum 3j to iv. The balsams and creosote 
are directly indicated in foetid bronchitis. Retention of secretion 
which does not yield to the action of drugs, may be treated by rhyth- 
mical compression of the chest during expiration. Potas. iodide gr. 
v to x t. i. d. is often excellent. 

4. Cardiac Weakness. — Cardiac weakness is relieved most effica- 
ciously by strychnine, which is more valuable than digitalis. 

5. Coincident Emphysema. — Coincident emphysema and asthma 
(q. v.) necessitate the prolonged use of iodides and belladonna. 



(C). FIBRINOUS BRONCHITIS. 

Etiology. — There are three types of fibrinous or croupous bronchitis. 
(a) The 'primary form is an infrequent disease, of which but few more 
than 100 cases are recorded; it occurs in males (66 per cent, of cases) 
principally in those between ten and thirty years, and in weakly and 
ansemic subjects; it results from bacteria, as the Bacillus diphtheria?, , 



FIBRINOUS BRONCHITIS 501 

pneumococcus, strepto- and staphylococcus, aspergillus fungus, and 
protozoa, or from their toxins, (b) The secondary type develops by 
extension from laryngeal and pulmonary disease, or in infections, as 
pneumonia, typhoid, measles, and scarlatina; tuberculosis causes 50 
per cent, of this group ; some cases occur in skin diseases, (c) Mechan- 
ical, thermal, and chemical agents are causative factors in a few cases, 
and some have occurred in connection with valvular heart disease and 
exophthalmic goitre. Fibrinous bronchitis was first described by Clark, 
in 1697. 

Symptoms. — The early symptoms are those of bronchitis, sometimes 
with fever, chills and haemoptysis, but they are ambiguous until bron- 
chial casts of fibrin or mucin are expectorated; this usually happens 
after a severe coughing paroxysm. The casts may measure even eight 
inches long, and may be as thick as a lead pencil or a finger; their upper 
and larger parts are circular or somewhat flattened, solid or hollow, 
but the lower small portions are branched, solid, spiral and often 
clubbed at their tips. Though usually termed fibrinous or croupous, 
many casts do not take Weigert's fibrin stain but respond to tests for 
mucin; these are then cases of bronchitis mucinosa or pseudomem- 
branacea. Liebermeister (1904) holds that fibrinous is more frequent 
than mucous formation. The microscopic appearance of the casts is 
hyaline, their texture is fibrillar, and their surface is often covered with 
blood disks, hsematoidin, or Charcot-Leyden crystals. Smaller casts 
may not be seen until the sputum is agitated in water, which washes off 
the adherent blood, pus or mucus; this may explain their frequency as 
an accidental finding. Pending their evacuation, there are signs of 
unilateral bronchial stenosis, dyspnoea, cyanosis, and inspiratory re- 
traction, and there are no breath sounds in the corresponding lung 
area. Slipping or moving of the casts in the bronchus may cause 
peculiar rales. After their evacuation new casts form in one or more 
days. Niemeyer observed the daily shedding of a complete cast of a 
bronchus and its divisions. 

Diagnosis. — In some cases casts are not voided during life, so that 
the autopsy alone determines the diagnosis. Asthma (q. v.) and bron- 
chitis fibrinosa have certain common symptoms, as paroxysmal 
occurrence, eosinophilia and the crystals and spirals, but are usually 
differentiated with ease. 

Course and Prognosis. — In the acute form, which lasts two weeks or 
less, there is great risk of sudden asphyxia during the evacuation of the 
casts; there is a death rate of 75 per cent, in the young and 50 per cent, 
in adults. In chronic forms the process lasts for months or even years, 
(cases of twenty-three and twenty-five years' duration have been 
observed). The prognosis is uncertain. Complications include 
splenic tumor, pneumonia, pleurisy, emphysema, and albuminuria 
which results from dyspnoea. 

Treatment. — Treatment is unsatisfactory if not wholly futile. In- 
halation of steam and alkaline vapors and pilocarpin should be given 
in order to loosen the casts. Emetics may be employed to facilitate 



502 DISEASES OF THE RESPIRATORY TRACT 

their evacuation, and iodides and mercurial inunctions to inhibit their 
reformation. The iodides are the most effective. 



(D). BRONCHIAL DILATATION, BRONCHIECTASIS. 

Etiology and Pathology. — Laennec first described bronchiectasis, in 
1819. It is found in 2 per cent, of autopsies and is always secondary 
(a) to bronchial disease, stenosis, catarrh, inhalation of dust, foreign 
bodies, or pressure from aortic aneurysm; (b) to lung disease, tuber- 
culosis, interstitial pneumonia (Corrigan), hypostasis, or atelectasis; 
(c) to pleural disease, such as adhesions pulling on the bronchi. Nearly 
all cases are acquired, and occur mostly in middle aged males (77 per 
cent.). Rare congenital cases are recorded. These may be divided 
into (i) the unilateral, universal or diffuse form (Grawitz), (ii) those 
due to congenital atelectasis (Heller), and (hi) those resulting from 
prenatal bronchial (syphilitic) stenosis. 

There are two forms of bronchiectasis: (a) the cylindrical or fusiform, 
multiple or pater noster form, which develops from the atrophy of the 
muscular and elastic fibers induced by protracted severe coughing and 
perhaps by stagnation of secretion; it may follow measles, catarrhal 
pneumonia, whooping cough or emphysema. (6) The rarer sacculated 
form, in which the bronchus may reach a diameter of even 3 inches, 
and which might be called a bronchial aneurysm. . The connective 
tissue usually disappears, the ciliated epithelia are replaced by flat cells 
and the mucosa is thin, red, and swollen, and sometimes presents 
villosities and varicosities. The sacs may become closed at their necks, 
particularly when caused by aneurysm, syphilis, or tuberculosis; this 
converts them into sacs filled with gelatinous, cheesy or calcareous 
contents. They are known as lung stones, and consist of calcium car- 
bonate and phosphate with traces of magnesia; they have an organic 
nucleus and sometimes cause " bronchial colic," or symptoms like those 
of phthisis. 

Bronchiectasis is seldom single; in multiple bronchiectasis the lung 
sometimes resembles a sponge or porous cheese. It occurs principally 
in the lower lobes and in bronchi of the third and fourth order. It may 
be bilateral (60 per cent.) but the congenital pleuritic and pneumonic 
forms are always unilateral. Adhesions are very common when the 
cavity reaches the pleura. 

Symptoms. — Most cases are not discovered clinically, and Weil 
therefore concluded that "most cavities escape detection and most 
diagnoses of cavities are incorrect." Sacculated forms produce more 
symptoms and signs than do the cylindrical forms, which are almost 
always impossible to recognize. 

1. Sputum and Cough. — The sputum and cough are paroxysmal. 
When secretion fills the sac and flows over onto the normal sensitive 
mucous membrane beyond it, cough develops and quantities of muco- 
pus are voided in the "mouth full" fashion described by Wintrich. 



BRONCHIAL DILATATION, BRONCHIECTASIS 503 

Change of posture produces similar effects. The largest amount is 
raised in the morning and this is frequently followed by vomiting. The 
daily quantity may amount to a quart. Its odor is acid, sweat-like, and 
offensive, but it does not attain the fcetor of putrid bronchitis nor the 
mature foulness of gangrene. When collected it forms in three layers; 
the upper one is foamy, the middle one is serous, and the lower one is 
purulent. A nummular or globular sputum may be noted as in tuber- 
culosis, but if put in water it is more flocculent, more granular, and air- 
less; and microscopically it contains altered leukocytes and fatty 
needles, occasionally red cells, hsematoidin crystals, and very rarely, 
when the bronchial wall is ulcerated, elastic fibers. 

2. Physical Examination. — (a) Inspection may reveal diminished 
respiratory movement, inspiratory retraction over the cavity, or flattening 
of the chest wall. The patient leans toward the diseased side, and rarely 
inclines toward the sound side or sits erect, in order to lessen the 
trickling out of the secretion. In the rare cases of bronchiectasis in an 
upper lobe the constant escape of the secretion results in exhausting 
and most unfavorable coughing (Skoda). The x-rays may show the 
location of the cavity, (b) Palpation and (c) percussion give variable 
results depending on whether the cavity is full or empty. Dulness 
prevails when it is full ; when it is empty a tympanitic note results. A 
higher note on opening the mouth, on inspiration, or on change of 
posture has the same value as in cases of tuberculous cavity (q.v.). 
(d) On auscultation, bronchial or metallic breathing may be heard when 
the cavities are superficial but it is absent in dilatations which are 
small, deep, or full of secretion. Large and small rales, if heard per- 
sistently in the same locality, are suggestive of a deep bronchiectasis. 
The sound tissue over the cavity imparts a metallic consonance. Meta- 
morphosing breathing is a certain sign of a cavity. 

3. Complications. — The general nutrition sometimes remains nor- 
mal; slight cyanosis together with ansemia is frequent. Hectic fever 
is often absent, but death may result, with symptoms resembling those 
of phthisis. Putrid bronchitis is frequent. Haemoptysis from ulcer- 
ation of ruptured varices occurs in 40 per cent, of cases; pneumo- 
thorax, pleurisy, empyema, lung induration or gangrene, emphysema, 
lobular pneumonia, amyloidosis and hypertrophy and dilatation of 
the right ventricle are fairly common. Marie's osteo-arthropathie 
hypertrophiante pneumonique, rheumatoid affections (Senator), sup- 
purative meningitis or abscesses in the brain and cord are occasional. 
In rare cases the cavity may bulge through the interspaces. 

Diagnosis. — Diagnosis depends upon the character of the sputum, 
its paroxysmal voidance, and the signs of cavity formation. Differ- 
entiation is required (a) from tuberculous cavities; this is made by 
means of family history, habitus, the presence of elastic fibers and 
tubercle bacilli in the sputum, which are definitely determined by in- 
oculation ; the tuberculous cavities are most often apical, but frequently 
bilateral; they void less sputum and suffer less rapid variation in their 
physical signs. Bronchiectatic cavities occur mostly in the lower lobes, 



504 DISEASES OF THE RESPIRATORY TRACT 

void more sputum, less often induce hemorrhage and more frequently 
cause right heart changes, (b) From perforating empyema, in which 
cholestearin and hsematoidin crystals are far more frequent than in 
bronchiectasis; (c) from abscess; (d) from gangrene of the lung (v. i.); 
(e) from putrid bronchitis, in which there is no sudden volume of 
evacuated sputum nor signs of cavity; (/) from encapsulated pyopneu- 
mothorax, which may be very difficult of differentiation. 

Prognosis. — The immediate prognosis is rather favorable, but ulti- 
mate recovery is exceptional. 

Treatment. — The therapeutic indications are (a) evacuation of the 
secretion, for which expectorants and expiratory compression of the 
chest, as in bronchitis, are somewhat useful; sedatives should never 
be given, lest gangrene develop; (b) modification of putrescence by 
balsamic remedies, as in foetid bronchitis; inhalations of creosote may 
be given, though they are most irritating at first; a dram of creosote 
is slowly vaporized over a flame, and the patient, in a closed room, in- 
hales the fumes with the eyes closed and the anterior nares plugged; 
the procedure may be gradually lengthened from a few minutes to half 
an hour; (c) surgical drainage. An accessible cavity may be incised 
and drained, though accurate diagnosis of its location is difficult. In 
Garre's collection of 57 cases (1902), 63 per cent, recovered and 37 per 
cent, died; (d) change of climate (v. Tuberculosis). 



(E). TRACHEAL AND BRONCHIAL STENOSIS. 
1. Tracheal Stenosis. 

Etiology. — The cause is less often within than without the trachea. 
Tracheal causes are rhinoscleroma (Stoerk, 1874), syphilis which in 
40 per cent, of cases also implicates the bronchi, tumors (cancer, polyp, 
fibroma, enchondroma, sarcoma, cancer or aberrant thyroid), foreign 
bodies, tracheotomy granulations, and in rare cases perichondritis. 
Causes outside the trachea are more frequent, as thyroid enlargement 
particularly the retrosternal, cystic and circular forms, or struma in 
which hemorrhage or inflammation has occurred; in some cases sudden 
death results, notably when the cartilages have been absorbed. Aneu- 
rysm, adenopathies, mediastinal tumors, vertebral tumor or caries 
and thymus hyperplasia are other factors. 

Symptoms. — The symptoms may be ranged in three series or stages; 

(a) when there are no symptoms or when they occur only on exertion ; 

(b) when there is constant dyspnoea, and (c) when suffocative attacks 
terminate in final asphyxia. The dyspn&a is of a mixed type, i. e., it 
is both inspiratory and expiratory; the number of respirations is 
lessened, there is inspiratory stridor and intercostal retraction, all the 
accessory muscles come into play, the head is held well forward and 
there is little or no laryngeal excursion. The pulse is more tense, varies 



TRACHEAL AND BRONCHIAL STENOSIS 505 

in rate, and is sometimes of the paradoxical type. Tracheoscopy may 
reveal the location of the lesion. This is done most advantageously in 
the strong sunlight; the patient should stand with his back to the light 
and with the head bent forward, and the observer should be seated on a 
low seat before him. Fraenkel affirms that m 25 per cent, of tracheal 
stenoses due to tumor or aneurysm, there is coincident paralysis of the 
vocal cords. 

2. Bronchial Stenosis. 

Etiology. — Intrabronchial causes are most common and consist of 
pus, mucus, blood, fibrin and foreign bodies; obstruction due to the 
latter is laryngeal in 33 per cent., tracheal in 26 per cent., and bronchial 
in 41 per cent., of the cases. Extrabronchial factors are next in fre- 
quency; aneurysm, mediastinal lymphosarcoma and perilymphade- 
nitis leading to fibrosis occur most often ; less common are pericarditis 
with effusion, dilatation of the left auricle, cancer of the oesophagus, 
tumor of the lung, and thyroid or thymic strumas. Twenty cases have 
been reported in which lymph glands ruptured into the trachea or 
bronchi, causing suffocation; only three were saved by tracheotomy. 
Interbronchial causes {i.e., in the bronchial wall) are the least common, 
as syphilis, glanders, rhinoscleroma and tumors. Thirty-six cases of 
primary cancer are recorded. The right is stenosed nearly twice as 
often as the left bronchus. 

Symptoms. — Occlusion of a bronchus lessens the amount of air en- 
tering the lung which it supplies,, whence the vocal fremitus and breath 
sounds are immediately weakened or suspended and the respiratory 
excursion and Litten's diaphragmatic sign are decreased. There is 
inspiratory retraction of the intercostal spaces on the affected side. 
Inspiratory dyspn&a occurs, particularly in acute cases. The head is 
thrown forward and the larynx moves up and down but little. The 
percussion note is not essentially altered, and this excludes many 
causes of dyspnoea, as pneumonia, etc.; after a time a somewhat 
tympanitic note may result from relaxation of the lung or acute emphy- 
sema. A local stenotic murmur over the bronchus is present in a few 
cases. Paroxysmal dyspnoea may result from stagnating secretion. 
The pulse is more tense and often slower. The rr-rays may locate the 
obstruction. Bronchoscopy is sometimes helpful, but it is difficult to 
perform even for the experienced specialist. Death results from (a) 
the original disease, as aneurysm or tumor; (b) failure of the right 
heart, (c) asphyxia, with delirium, cyanosis, convulsions or Cheyne- 
Stokes breathing, or (d) pulmonary oedema, abscess, gangrene, tuber- 
culosis, lobular pneumonia, lung induration or hemorrhage. 

Diagnosis. — (a) Of the location of stenosis : in laryngeal obstruction, 
there are local findings and free up-and-down excursion; the subject 
holds the head well back, and the ingress of air to both lungs is equally 
impaired; tracheoscopy, bilateral lung involvement, the absence of 
laryngeal excursion, and the holding of the head forward are sufficient 



506 DISEASES OF THE RESPIRATORY TRACT 

proof of tracheal obstruction ; in bronchial stenosis but one lung suffers 
for air, the larynx is nearly immobile, and the head is thrown forward. 
(b) Of the nature of stenosis, exact diagnosis is more difficult, and is 
impossible without distinct physical signs, as those of aneurysm, or 
without history of the presence of foreign bodies. 

The prognosis depends on the cause. 

Treatment. — Treatment is also largely that of the cause, as syphilis, 
tuberculosis, etc. Thyroid extract and iodine are efficacious in over 
50 per cent, of cases of thyroid swellings. When the obstruction is 
aneurysmatic, rest, mercury, iodides, venesection and gelatin injections 
often afford considerable relief. When there are foreign bodies, the 
patient should be inverted, sharply struck on the back, and shaken; 
the physician should have long forceps and tracheotomy instruments 
in readiness. The mortality from the presence of foreign bodies in the 
lower air passages is 52 per cent, with expectant treatment, and 23 per 
cent, with operation. 

Bronchial and lung stones (v.s.) result from tuberculosis of the 
bronchial glands, from bronchiectasis, petrification of the bronchi, 
calcification and ossification of the lungs, and from gout and the 
presence of foreign bodies. Symptoms are frequently absent or are 
those of the primary disease; purulent bronchitis, asthma (" bronchial 
colic"), hectic fever and haemoptysis mark some cases. 

Stenosis of the bronchioles may result from bronchiolitis fhrinosa 
obliterans (Lange and Fraenkel). 



(F). BRONCHIAL ASTHMA. 

Definition. — A paroxysmal dyspnoea, due to stenosis or spasm of the 
smaller bronchioles, which is nervous or reflex in origin and is charac- 
terized by expiratory dyspnoea, slowing of respiration, congestion of the 
bronchioles, a peculiar mucous exudation and acute emphysema. It 
is also known as asthma spasmodicum or nervosum, to distinguish it 
from other so-called asthmas, as the cardiac or renal types. 

Etiology. — When due to no obvious cause, asthma is termed essential 
or "primary, and when due to a clear cause it is called symptomatic or 
reflex asthma (which occurs through the vagus), (a) Nasal and naso- 
pharyngeal disease is the source of the reflex asthma in numbers of 
cases, as proven by Voltolini, Hack, Haenisch, Porter, Daly, Roe and 
others; it may be caused by rhinitis, tonsillar hypertrophy, adenoids, 
or pharyngitis granulosa; the nose may be so hypersensitive that the 
odor of flowers, dust, hot air or smoke precipitate an attack. (6) 
Asthma may be initiated by pressure on the vagus trunk, resulting 
from thyroid tumors or from enlargement of the bronchial glands, 
following tuberculosis, measles, pertussis, or rickets, (c) Abdominal 
diseases are possible though not frequent causes; the asthma dyspepti- 
cum of Henoch, Meyer and Pribram has been especially emphasized 
of late by Hayem who describes asthma resulting from gastric dila- 



BRONCHIAL ASTHMA 507 

tation. Ovarian and uterine disease and pregnancy have been con- 
sidered causal factors, (d) Asthma toxicum has been reported in lead 
and mercurial poisoning; urosmic and gouty asthma are also due to 
toxins, (e) It occurs especially in weakly, ansemic, nervous, scrofulous 
and rhachitic subjects, in males (66 per cent.) between the age of twenty 
and forty (though it has recently been claimed that 33 per cent, of the 
asthma cases develop under ten years), in the upper classes, and in 
professional men. 

There are various theories as to the mechanism of the asthmatic 
attack; these are as follows: (a) it is a spasm of the bronchial muscles 
(Trousseau, Rhomberg and Biermer). Trousseau spoke of asthma as 
"an epilepsy of the lungs"; (6) it is a very acute catarrh (Louis and 
Traube); Stoerk found the larynx and trachea deeply injected; (c) it 
is a vasomotor disturbance (Weber) ; or (d) an acute exudative bron- 
chitis, causing bronchial spasm (Curschmann, Lebert). Its pathology 
is uncertain, as but half a dozen autopsies are recorded; the ciliated 
epithelium is desquamated, the bronchioles are congested and there is 
eosinophilic exudation. 

Symptoms. — The attack begins very suddenly, often at night and 
with or without such causes as fright, cold, heat, change of residence, etc. 
Sometimes there are prodromes, as conjunctivitis, coryza or flatulence 
and sometimes the attack coincides with the menses, (a) Dyspnoea is 
the first and the essential symptom; though at first slight, it soon be- 
comes urgent; the patient opens the windows, sits upright, grasps the 
arms of the chair to brace the accessory respiratory muscles, and ex- 
hibits extreme distress, anxiousness and pallor, which is followed by 
cyanosis; the dyspnoea is expiratory, and the abdominal muscles are 
board-like during expiration; inspiration is somewhat lengthened, and 
expiration is greatly prolonged, wheezing, and whistling; respiration is 
not usually increased, but may reach 30 or 40. (6) There is marked 
cyanosis in the face and extremities, the cervical veins bulge out like 
cords, the skin is clammy, and the pulse indicates poor oxygenation 
by its tenseness, smallness and frequency ; carbon dioxide intoxication 
causes the occasional headache, delirium, tinnitus, twitchings, convul- 
sions and coma, (c) The cough is dry and unproductive, (d) The voice 
is faint and hoarse and the trachea is red. (e) Other physical signs are 
as follows : On palpation, the vocal fremitus is found to be decreased 
by the bronchial spasm or secretion ; rales are often felt. The normal 
percussion note is replaced by a tympanitic note, due to acute pul- 
monary emphysema; the lungs are voluminous, and distend the thorax, 
cover the heart and push down the diaphragm, whose excursion is thus 
reduced to a minimum. On auscultation, the vesicular murmur is 
usually found to be faint or absent (Laennec) because of secretion in 
the bronchioles, and loud whistling, piping, or sibilant rales are heard 
often without the stethoscope and largely during expiration. They are 
due to bronchial stenosis. (/) Sputum is voided for the first time 
toward the end of the attack; this occurs as a species of crisis to the 
threatening, but very seldom fatal, asphyxia. A few drams of 



508 



DISEASES OF THE RESPIRATORY TRACT 



tenacious mucus, resembling egg albumin or gelatin, are voided. 
Minute gray balls are seen; these are the " perles" of Laennec; when 
unrolled the " pearls" are seen to contain the spirals of Leyden, Ungar 
and Curschmann ; they are best detected with the naked eye, and on a 
black background; they measure 2 or 3 to 10 x h to 1 mm.; they 
are mucin casts of the bronchioles, to which may cling leukocytes, 
epithelia, fat or myelin droplets; some show a central band of mucin; 
it is thought that they occur from the passage of mucin through the 

Fig. 32. 





Spirals and crystals in bronchial asthma. B, , Charcot-Leyden crystals; A, spirals magnified, and 

C, their natural size. 

contracted bronchioles ; they disappear within a day or two ; spirals are 
also present in catarrhal or fibrinous bronchitis and in pneumonia. 
The Charcot-Leyden crystals may be seen in yellow dots in the sputum ; 
their origin is still disputed; they are pointed and octahedral, consist of 
an organic basis with phosphoric acid, and are also seen in leuksemic 
tissues, in normal bone marrow, and in semen, Hemosiderin may be 
found in the sputum. The eosinophile leukocytes are increased in the 
sputum and blood, constituting a quarter to more than half of the 
white cells. The crystals, spirals, and the occasional fibrinous casts are 
a result rather than a cause of the asthma. (Plate X.) 

The attacks last from a few minutes to several hours and may be 
repeated at long or short intervals. In the hebdomadal form, attacks 
recur every Sunday or Monday; they are probably due to change in 
routine or to digestive excesses. The urine after the attack contains 
increased uric acid; constipation and flatulence may result from 
fatigue of the diaphragm and expiratory muscles. 

Diagnosis. — The diagnosis is made by (a) the paroxysmal occurrence 
of asthma, (b) the expiratory dyspnoea, and (c) the acute transient 
emphysema. 

Differentiation. — (a) All diseases causing inspiratory dyspnaa can be 
at once excluded, such as oedema or spasm of the glottis, paralysis of the 
post, crico-arytenoid muscles, and tracheal and bronchial stenosis from 



PLATE X. 






■•I;?.-." 



*mW 












■'•if 

#5H « 






,;# 









** 



* .../' 



l 5 ^ 



. 



.. • ^s.-.v";-. 



^ 



i>$ 



X* * 



:,, 



Sputum from a Case of Bronchial Asthma, showing large numbers 
of Eosinophilic Leukocytes and Free Granules. (Simon). 



It will be noted that the leukocytes are all mononuclear. (Eye-piece 1, objective 1-8, Bausch & Lomb.) 



BRONCHIAL ASTHMA 509 

aneurysm. In spasm of the glottis, the spasm is inspiratory and of short 
duration, the larynx moves up and down, and the epigastrium retracts 
during inspiration; there is no emphysema, and no spirals are found. 
Spasm of the diaphragm is very rare (v. Phrenic Nerve) ; it lasts a 
much shorter time, the epigastrium bulges during inspiration, there is 
spasm of all the inspiratory muscles, hysterical stigmata are often 
observed, and the lungs are normal. (b) Expiratory dyspnaa may also 
occur in (i) chronic bronchitis with emphysema. In these cases the 
emphysema is constant, the lungs show constant rales and fewer 
eosinophiles are present in the sputum, (ii) It also occurs in immov- 
able tumors below the vocal cords which may turn upward during 
expiration (this is shown by the laryngoscope), (c) Asthma cardiale 
(so-called) is of a mixed type, i. e., inspiratory and expiratory, and 
is therefore readily differentiated. The "lungenstarr" or lung dis- 
tention (v. Signs of Valvular Heart Disease), due to its engorged 
vessels, may simulate the emphysema of bronchial asthma. Cardiac 
asthma may occur either with high or low arterial tension, whence 
the condition of the pulse is no certain criterion. The eosinophiles 
are not increased to the same degree as they .are in bronchial 
asthma. 

Prognosis. — The prognosis is uncertain and depends on the etiolog- 
ical accessibility of the asthma. It is more favorable in young individ- 
uals than in those of advanced years. Cases which recurred for 64 
years are recorded. Chronic bronchitis and emphysema are likely to 
develop. 

Associated affections may include epilepsy, migraine, angina pectoris 
or vasomotor disturbances. 

Treatment. — 1. Of the Attack. — A hypodermic injection of morphine, 
gr. j, with atropine gr. so and nitroglycerine gr.-so, gives the most prompt 
and reliable results. Other measures are purely accessory. Chloral is 
almost useless, for the condition usually requires single doses of gr. 
xxx to xl, which are too large for safety. Fresh air, strong coffee, 
whisky, a cigar or cigarette, the application of cocaine to the nose, 
fluid extract of grindelia tt#. x to xx especially in bronchitic types, nitrite 
of amyl pearls, or a few whiffs of chloroform, sometimes give relief. 
The vexing question arises as to leaving chloroform or morphine in 
the hands of the patient whose attacks often come and go without 
medical aid; as a rule they should never be left with the patient. 
Inhalation powders, which are burned like incense, are very generally 
used; they all contain some such palliative as lobelia, stramonium, 
belladonna, hyoscine, etc. (Lobelia, powdered black tea and powdered 
stramonium leaves, each one ounce; soak well in two ounces of a satur- 
ated solution of potassium nitrate; dry.) Excellent cigarettes are made, 
containing arsenic, potas. nitrate, belladonna, and stramonium; their 
antispasmodic effects on deep inhalation of the smoke is sometimes 
remarkable. 

According to Burney Yeo, the celebrated Cigarettes d'Espic are said 
to be made of the following ingredients : 



510 DISEASES OF THE RESPIRATORY TRACT 

Belladonna leaves 5 \ parts. 

Hyoscyamus leaves 2| parts. 

Stramonium leaves 2| parts. 

Phellandrium aquaticum 1 part. 

Extract of opium \ part. 

Cherry-laurel water a sufficiency. 

Oxygen is occasionally efficacious and strong coffee may sometimes 
abort the attack. 

2. Of the Tendency. — (^.Etiology.) — The nose requires especial 
attention; cauterization of sensitive areas, even when there are 
no gross lesions, is imperative. The diet should be regulated; the 
evening meal should be light, and carbohydrates and tea should be 
restricted; an emetic may abort an attack of the gastric type. Nervines 
(valerian, arsenic, bromides) may be used when necessary. The best 
remedy between attacks is potassium iodide; this treatment should be 
continued for months; potassium iodide is combined to advantage 
with Fowler's solution and belladonna, not only to correct the action 
of the iodides on the skin and secretory glands, but also for their 
direct nervous and antispasmodic effects: 

Liq. potassii arsenitis 5|. 

Tr. belladonnse oj. 

Potassii iodidi oij. 

Fluidextr. grindeliae robustae 5vj. 

Aquae q.s. ad oiv. 

M. et S. — One teaspoonful after meals, in water. 

Alkalies may be vaporized and inhaled, as sodium bicarbonate or 
sodium chloride. Climatic treatment is as beneficial as in bronchitis; 
a low level near the sea and in a semitropical climate is an ideal loca- 
tion. General hygiene and the hardening of the patient by fresh air 
and cold rubs are important. 



DISEASES OF THE LUNG. 

(A). EMPHYSEMA. 

Definition. — A permanent disease of the lungs, characterized patho- 
logically by atrophy of the alveolar walls and great distention of the 
alveoli, and clinically by a large chest of the inspiratory type, distended 
lungs with poor excursion, and hypertrophy and dilatation of the right 
ventricle. Emphysema means a " blowing up" or distention of the 
lungs, of which the various types will be considered under Differ- 
entiation. It was first described by Laennec (1826). It constitutes 
i 7 o per cent, of all autopsies (Virchow). 



EMPHYSEMA 511 

Etiology. — Substantive or alveolar emphysema occurs mostly in 
individuals over 30 or 40 years of age, in men more than in women, and 
in cold climates. The immediate cause is chronic bronchitis and 
bronchiolitis (Laennec), catarrhe sec; it may follow pertussis or bron- 
chial asthma; its comparative infrequency is not generally understood, 
whence many writers assume a congenital or hereditary weakness or 
hypoplasia of the elastic tissue of the lung. Coughing, blowing, as in 
the use of wind instruments, straining during parturition or physical 
toil, artificial respiration in the new-born, and alcoholism are also con- 
sidered to be causes. 

Pathology. — On opening the chest at autopsy, the lungs are found 
distended (volumen pulmonum auctum, Traube); they overlap the 
heart, depress the diaphragm, and narrow the mediastinum. Their 
surface is pale rose-colored, is somewhat anaemic, and presents numer- 
ous small vesicles, J to 3 or 4 mm. in diameter, representing the fusion 
of several alveoli. Some large bullous areas are found under the pleura. 
The lungs crepitate slightly to the fingers, under which they feel, as 
Laennec put it, "like a pillow of down." The lungs collapse but little 
on section. In some places the pigment deposit is less than usual; this 
is called albinism by Virchow. Emphysema is most marked on the 
surface of the lung, particularly over the upper lobes, on their convex 
anterior aspect, and behind near the spine. The normally thin edges 
of the lung are greatly rounded. Histologically, two findings are char- 
acteristic: (a) There is atrophy of the interalveolar elastic tissue, so 
that the alveoli fuse, corresponding to the vesicles seen on the surface; 
slight intercommunication of the alveoli is normal, but the coalescence 
of several alveoli into one is extreme in emphysema; these changes 
account for nearly all the clinical findings in the lung, (b) The 
capillaries are obliterated by thrombosis, and become fatty, which 
explains the clinical hypertrophy, dilatation and ultimate failure of the 
right heart. The bronchi are frequently inflamed, thickened, shortened, 
and sometimes dilated. 

Pathogenesis. — It is not wholly clear whether the elastic wasting or 
the vascular occlusion is the primary change; or, if the elastic atrophy 
is primary, whether it is acquired or congenital. The changes may be 
brought about (a) mechanically by forced inspiration (Laennec, Roki- 
tansky, Gairdner) or by forced expiration (Jenner, Mendelsohn). 
This theory is most favored by clinicians, though pathologists think 
that emphysema is due to (b) nutritive alterations, as vascular changes, 
or atrophy of elastic or muscular tissue; calcification of the costal carti- 
lages is probably more sequential than causal. 

Symptoms. — Symptoms may be considered under two general 
headings: (1) Those of expiratory insufficiency of the lungs, due to 
their distention which results in turn from the loss of elastic tissue; and 
(2) those of cardiac insufficiency, which follow the above and result 
from obliteration of the vessels in the lesser circuit. 

1. Expiratory Pulmonary Insufficiency. — Normally expiration is 
wholly passive, resulting from the elasticity of the lungs and collapse of 



512 DISEASES OF THE RESPIRATORY TRACT ■ 

the chest. Expiration in emphysema is incomplete, as shown by 
Waldenburg's pneumotometry and Riegel's stethography; in the latter 
the curve resembles one resulting from division of the vagus. The 
cyrtometer shows that the chest is more circular; the spirometer shows 
a decrease of 20 to 60 per cent, in the normal vital capacity (2-4000 c.c.J; 
and mensuration shows a decided reduction in the normal expansion of 
2 to 3 inches. Upon inspection, dyspnoea is the most conspicuous 
finding; it is expiratory and is due to the loss of lung elasticity and 
consequent impairment of lung circulation and oxygenation; it is 
increased by exertion, by bronchial catarrh, by accessions of true 
asthma, and by cardiac insufficiency. If emphysema develops gradually 
it may cause no dyspnoea (Traube). The frequency of respiration is 
increased to twenty-five or thirty and the type is costal. The fades 
and habitus are most characteristic; the eyes are somewhat prominent, 
the nose is bluish and slightly thickened, the head is thrown back and 
the chest forward to give play to the accessory muscles of respiration, 
and the skin is cyanotic even during rest and when dyspnoea is not 
urgent. A network of dilated veins is often seen over the lower chest, 
resulting merely from venous obstruction. The jugular veins fill 
enormously on expiration and often pulsate during the diastole. The 
neck is short, and the hypertrophied sternomastoids, scaleni and trape- 
zii protrude rigidly. The back and abdominal muscles are rigid, and 
thus supplement the inadequate action of the diaphragm. The shoul- 
ders are elevated, though stooped; the chest is of the permanent inspira- 
tory type and is usually barrel-shaped (from loss of the elastic tissue), 
rarely of the paralytic type; the anteroposterior, oblique, and some- 
times the transverse dimensions of the chest are increased. The raised 
clavicles accentuate the supraclavicular notches, in which the apices 
sometimes protrude, on coughing, as hernial tumors. The angle of 
Louis is prominent and the interspaces are wider in the upper and 
narrower in the lower parts of the chest, and retract with each inspira- 
tion. The lower thorax shows a groove indicating the attachment of 
the expiratory muscles. The play of the diaphragm is limited, as 
shown by the arrays and by the absence of Litten's sign. Palpation 
detects the rigidity and dilatation of the thorax, its poor excursion, the 
hardness of the muscles, the thick, often calcified costal cartilages, and 
decreased vocal fremitus. The edge of the liver may be found de- 
pressed, though the spleen is seldom palpable. Percussion, absolutely 
essential to a diagnosis, gives a note which is loud and deep — hyper- 
resonant — or on the sides and back it is actually "box-like" or tympan- 
itic; it is also described as muffled or wooden and in extreme cases 
impresses one as dull (Skoda). The voluminous lungs narrow or 
wholly cover the cardiac dulness, depress the upper level of the splenic 
and hepatic dulness, invade Traube's space, and show either no 
respiratory excursion or movement not exceeding a finger's breadth. 
At the back the lungs may reach the twelfth dorsal or even the second 
lumbar vertebra. Upon auscultation, expiration is found greatly length- 
ened so that it is to inspiration as 1 to 2 or 4, the converse of the nor- 



EMPHYSEMA 513 

mal. Vesicular breathing is absent, or the breathing is indeterminate; 
even when the stethoscope rises and falls there may be no audible 
sound. A rubbing sensation may result from muscular contraction or 
possibly from the emphysema vesicles. Rales result from bronchitis 
or stasis; a pearly-colored mucin with few cells may be evacuated 
after much coughing. 

2. Cardiac Insufficiency. — The work of the right ventricle is in- 
creased because the imperfect expiration allows neither free aspiration 
of venous blood into the auricles nor adequate filling of the aorta, and 
because the pulmonary arterioles are in part occluded. The right 
ventricle, therefore, hypertrophies, and this causes the accentuated 
second pulmonic tone; hypertrophy occurs mostly about the pul- 
monary conus arteriosus. The diaphragm is low, and therefore the 
hypertrophied and more horizontal heart beats in the epigastrium. 
Dilatation soon follows and is accompanied, in advanced cases, by tri- 
cuspid leakage, nutmeg liver, congested kidneys, ascites, oedema, and 
other signs of cardiac insufficiency. The alteration in the heart, so 
marked at autopsy, is often obscured during life, for the lungs cover the 
heart and muffle its tones. Functional heart murmurs are mostly 
systolic, very rarely diastolic, and result chiefly from degeneration or 
relaxation of the heart muscle. 

The clinical course is long and often covers decades. Patients 
may acquire emphysema in childhood and live to be 60 or 70 years old. 

Diagnosis. — Developed types are easily recognized by the barrel- 
chest, its hyperresonance, the low borders of the lung, their lack of 
excursion, the obscuration of cardiac dulness, the expiratory dyspnoea, 
and cardiac stasis. 

Differentiation. — (a) Acute distention of the lung or acute emphy- 
sema, as after asthma or pertussis, cannot be distinguished by one ex- 
amination. It is seen repeatedly in bronchial stenosis due to aortic 
aneurysm. It regresses rapidly even after months, when its cause is 
removed. (b) Vicarious or compensatory emphysema often develops in 
one lung when contralateral pleurisy or cirrhosis of the lung exists; it 
may occur on the same side with the lesion ; marked apical emphysema 
almost certainly indicates some deeper induration; it may develop in 
the death agony; it may eventually cause wasting of the lung, (c) 
Emphysema senile, or Jenner's "small-lunged" emphysema, is merely 
atrophy; the connective tissue wastes and the alveoli fuse, but the 
lungs are not enlarged; they are indeed smaller, the diaphragm stands 
higher, the cardiac dulness is increased, the chest flattened, the ribs 
oblique, the respiratory muscles wasted, the right heart is not hyper- 
trophied, and respiratory excursion is retained, (d) From interalveolar 
interstitial emphysema the first differential point is the etiology; (i) it 
may be caused by trauma, external or internal, which occurs in 57 per 
cent of tracheotomies (Money), and is promoted by raising the deep 
fascia from the trachea during the operation (Champneys); it is es- 
pecially frequent with pneumothorax, (ii) It may result from foreign 
bodies, (iii) Ulceration of the air passages, gangrene, abscess, or 

33 



514 DISEASES OF THE RESPIRATORY TRACT 

tuberculosis and less often gastric ulcer or cancer may be its cause. 
Other etiological factors are (iv) forced entrance of air, as in resuscita- 
tion of the new-born; (v) severe coughing efforts, as in whooping 
cough; (vi) severe pressure efforts, as in parturition; and (vii) spasm 
of the glottis. The second point is a series of symptoms which are not, 
however, always present, as creaking in the mediastinum and some- 
times with each systole; emphysema and crepitation of the cervical 
cellular tissue, bulging of the interspaces, creaking and tympany at the 
edge of the ribs when the emphysema is under the costal pleura ; ab- 
sence of the vesicular murmur; sometimes pneumothorax; and obliter- 
ation of the heart dulness, dyspnoea and air embolism. It is usually 
fatal, (e) In congenital hypertrophy of the lung (pulmo excessivus) 
the lungs are very voluminous, but their excursion, note, auscultation, 
and percussion are normal. To the author it appears to be especially 
common among Poles. (/) Pneumothorax (q. v.) is unilateral, is 
usually associated with fluid in the pleura, has a more tympanitic 
note, and is associated with succussion, tinkling rales and other path- 
ognomonic signs. 

Prognosis. — Recovery is unusual in the genuine substantive form, 
which is permanent. Transient forms resulting from pertussis, foreign 
bodies, or asthma, often or usually regress completely. Life, even 
relative comfort, may be sustained for years or decades. Much depends 
on associated conditions, as frequent severe bronchitis, chronic nephri- 
tis, arteriosclerosis, or myocarditis. Extreme forms impede the flow 
of chyle which, with dyspnoea and fatigue, impairs nutrition. Severe 
complications are failure of the right heart upon which compensation 
devolves, cyanosis, gastric disturbance, diarrhoea, hemorrhage from 
the lungs or bowels (in arteriosclerosis, gout or infarction), scanty 
urine, and anaemia (in the aged). 

Death usually results from cardiac failure or from oedema pul- 
monum. It may occur from apoplexy, pneumothorax, haemoptysis, 
uraemia, and very rarely from pulmonary inflammation, to which 
subjects of emphysema show no predisposition. The teaching that 
tuberculosis (Rokitansky) or valvular disease (Bouillaud) exclude 
emphysema, is incorrect. 

Treatment. — (a) Prophylaxis concerns chiefly the concomitant or 
causal bronchitis. Severe exercise is to be avoided, (b) Coincident 
gastric, renal or gouty disease must be treated, (c) Climate is as im- 
portant a factor as it is in chronic bronchitis, an almost inseparable 
associate of emphysema ; altitudes are expressly to be avoided as they 
directly promote emphysema, (d) Pneumotherapy is sometimes bene- 
ficial. It includes inhalation of thinned air, or, where there is marked 
catarrh, of compressed air. Two or three treatments of ten minutes 
should be given daily, and the time should soon be extended to half an 
hour, (e) Chronic bronchitis (q. v.), and (/) asthma (q. v.) are impor- 
tant considerations in treatment, (g) Rhythmic compression of the 
chest, three or four times daily, should be practised during 20 to 30 
expirations, (h) Cardiac insufficiency is treated as in valvular or 



BRONCHOPNE UMONIA 515 

myocardial heart disease (q. v.), and strychnine, venesection, and other 
measures should be used. (The topic is discussed briefly, as no remedy 
nor measure can restore lost elastic tissue nor return resilience to 
damaged contractile fibers.) 



BRONCHOPNEUMONIA. 

This affection, partially outlined by Sydenham and Gebhart, was 
first well described in 1840, by Rilliet and Barthez, who separated it 
from lobar pneumonia and recognized it as a secondary disease. It 
might be well classed among the infections, such as fibrinous pneu- 
monia, except that unlike the latter it is not due to a single specific 
microorganism. 

Definition. — Bronchopneumonia is defined with difficulty; (a) 
etiologically it is due to various microbes, is generally secondary to 
the bronchiolitis of some specific infection, as measles or pertussis, and 
occurs chiefly in children; (b) pathologically it develops about the 
bronchioles (bronchopneumonia) and in a few lobules (p. lobularis, p. 
insularis or nodosa) rather than throughout a lobe, its exudate is 
rather catarrhal (p. catarrhalis) than fibrinous, and its distribution is 
usually multiple and often disseminated (p. disseminata); (c) clinic- 
ally it is identical with capillary bronchitis, which, if it occurs in the 
first years of life, almost never spares the lung tissue; it is marked by 
fever, cough, dyspnoea and cyanosis, which may often co-exist with- 
out obvious signs of hepatization. 

Etiology. — (a) Some cases, especially in children under two years, 
are primary; these are estimated by Holt at 35 per cent., by others at a 
much lower figure; (b) most cases are secondary to infections affecting 
the upper air passages. In 279 cases of infantile bronchopneumonia 
reported by Samuel West, 32 per cent, followed measles, 24 per cent, 
pertussis, 16 per cent, diphtheria, 15 per cent, macrobronchitis, 7 per 
cent, ileocolitis, 3 per cent, scarlatina, 2 per cent, influenza, \ per cent, 
each varicella and erysipelas, (c) Predisposing causes in the young are 
poor sanitation, malnutrition, syphilis, tuberculosis (scrofula), and 
rickets. Bronchopneumonia causes 9 per cent, of deaths in foundling 
asylums (Miiller). (d) Age is an etiological factor. Most cases are 
observed in children two or three years old. Seventy-five per cent, of 
cases of pneumonia in children under five years of age are lobular (Holt). 
It is less frequent in adults; in weak, cachectic, nephritic and aged per- 
sons it may cause death, (e) In some cases microbes may act directly on 
the lungs, as in the primary cases in children, in the influenza of adults, 
and in aspiration or inhalation pneumonia. "Schluck pneumonie" is 
prone to develop in diseases in which the laryngeal sensibility is de- 
creased as in diphtheritic pareses or bulbar palsies; in ether or less 
often chloroform ana3sthesia in which the germ-laden saliva is drawn 
into the lungs; in comatose states, as apoplexy, or uraemia; in mental 
diseases; in the new-born ; in cases of partial drowning; in operations 



516 DISEASES OF THE RESPIRATORY TRACT 

on the throat, as tracheotomy or those for foreign bodies or cancer of 
the larynx or oesophagus ; or when there is persistent vomiting. Smoke, 
vapors, gases and dust are exceptional causes. (/) It is probable that 
infection may sometimes occur by the lymph or blood streams, especially 
in septic affections. 

Bacteriology. — Bronchopneumonia is no specific bacteriological 
disease. According to Netter, in adults about one-third of the cases 
Show more than one organism, among which the pneumococcus ranks 
first and the streptococcus second ; and about two-thirds show one germ, 
of which the pneumococcus constitutes 39 per cent., streptococcus 31 
per cent., Friedlander's bacillus 23 per cent., and the staphylococcus 7 
per cent. ; in children mixed infection is present in half the cases, the 
streptococcus predominating, while in the other half there is but one 
organism, the pneumococcus being the most common. Others, as 
Deurck, maintain that most cases show mixed infection. Other germs 
found are the influenza, typhoid, tubercle and colon bacilli, Pfeiffer's 
Micrococcus catarrhalis, Micrococcus tetragenus, and meningococcus. 
The tubercle bacillus is often associated with the pneumococcus. 

Pathology. — The foci of consolidation are diffused usually in the 
lower and sometimes in the upper lobes, posteriorly. They vary in 
size from that of a pin head to that of a walnut, or may be larger; many 
or most foci lie near the pleura, through which they may often be seen 
and felt; the pleura is often granular or slightly fibrinous, sometimes 
ecchymotic. Foci are usually bilateral. On section the consolidated 
nodes appear reddish-brown and later yellowish from fatty degenera- 
tion of the cells ; they are firm, airless, whence they sink in water, and on 
section are generally smooth and glistening, though some cases of 
pneumococcus infection show the same granulation and viscid secretion 
which are present in genuine fibrinous pneumonia. The bronchioles 
supplying the consolidated nodes are plugged with muco-pus, so that 
air cannot be forced through them; the bronchioles are reddened, 
swollen, sometimes ecchymotic or dilated. Many parts are collapsed, 
which some consider is preliminary to consolidation, but though 
atelectasis is frequent its importance has been overestimated. In for- 
tunately made sections a dendritic racemose or grape-like arrangement 
may be seen in which the bronchioles correspond to the stems and the 
alveoli to the leaves or grapes. Microscopically the bronchioles show 
dilated vessels and leukocyte emigration, the alveoli show epithelial 
desquamation and proliferation, serous exudation, leukocyte out- 
pouring, a scattering of red cells and but little fibrin formation; the 
alveolar walls show much interstitial inflammation. It is usually 
stated that no fibrin is found, but this is a mistake; though influenza 
pneumonia is strictly cellular (catarrhal), aspiration, pneumococcic and 
other forms not infrequently show a fibrin network, though decidedly 
less than is the case in lobar types. Near the foci and in the upper 
lobes compensatory emphysema often develops. The bronchial lymph 
glands are hypersemic, swollen and succulent. Extension occurs 
directly from alveolus to alveolus or along the peribronchial connective 



BRONCHOPNE UMONIA 517 

tissue. In some forms numerous lobular foci may increase in size and 
perhaps fuse so that the greater part of a lobe may be consolidated; 
this form, known as the pseudolobular, is often due to the pneumococ- 
cus, is often seen in measles and diphtheria and may clinically present 
a close resemblance to lobar pneumonia, though pathologically areas 
of collapsed, dark vascular, or sound tissue lie between the broncho- 
pneumonic patches. 

Symptoms. — The clinical picture varies considerably, accordingly as 
the bronchopneumonia is primary or secondary. In the primary form, 
which is most often due to the pneumococcus, the onset is brusque, 
with chill, convulsions, vomiting, or pain in the side. The fever 
rises suddenly, remains high, and often falls by crisis. Capillary 
bronchitis is absent and the consolidation is often marked. The course 
is short and the death rate is low. In adults this form is frequently 
unilateral. The more common secondary form begins insidiously, 
especially if it follows a microbronchitis; it is often obscured by the 
disease which it complicates. The fever gradually rises to 103° or 104° 
(if fever were already present), and is generally irregular or remittent, 
rising with the formation of each new focus; it may be low or absent 
in marantic subjects. There may be no physical findings, or if present 
they are frequently indeterminate. If recovery ensues, lysis is the 
usual solution. Von Ziemssen held that fever in bronchitis seldom 
exceeds 102° and that higher registrations indicate pneumonia. 

Subjective and General Manifestations. — These are often more 
obvious than the objective or pulmonary symptoms. The pulse rises 
to 120 or even 180 and in convalescence is more tardy in reaching nor- 
mal than is the fever. The respiration is often 60 or 80, the expiration 
is frequently catchy or grunting, and the respiration ratio, normally 1 to 
4, becomes 1 to 3 or 2 ; dyspnoea develops early, and with it restlessness 
and irritability. Cyanosis develops in the face and then in other parts 
from impaired flow of the blood to the heart which is due to continued 
coughing and to stagnant secretion. The cervical veins are prominent. 
Pain is not as common as in lobar pneumonia. The cough becomes 
dryer and more distressing; the sputum is usually swallowed in patients 
under seven years of age, but if obtained shows nothing characteristic, 
though von Niemeyer found that it sank in water or floated under the 
surface. Meteorism is not uncommon in severe or moribund cases. 

Lung Findings. — On inspection, irregular excursion is sometimes 
seen. The accessory muscles of the nose, neck, chest, and abdomen are 
in full play. The interspaces, ribs, sternum, and epigastrium in young 
plastic chests, retract greatly with each inspiration; this must not be 
confused with the slight physiological retraction observed in the begin- 
ning of inspiration. Palpation may show increased fremitus in a focus 
near the surface and measuring 2x5 cm. Stagnant secretion in the air 
tubes may temporarily suspend fremitus. Percussion is often negative 
for a few days or even throughout the course, as it is obvious that deep, 
isolated foci cannot produce dulness. In the thin, infantile thorax, per- 
cussion must be made lightly and special importance should be attached 



518 DISEASES OF THE RESPIRATORY TRACT 

to palpatory percussion. Dulness obtains over a focus having an area 
of 2 x 5 cm. It is most often found along the spine over the lower lobes, 
but sometimes also over the scapular spines. Dulness is most marked 
in the pseudolobular (confluent) forms. Atelectasis may cause dulness 
but not bronchial breathing. A hyperresonant note in. front indicates 
emphysema; behind it shows relaxation. Auscultation reveals sub- 
crepitant or crepitant rales; they are often heard over an area not 
exceeding the bell of the stethoscope. Bronchial breathing and bron- 
chophony are fairly frequent, and occur especially when the child 
cries. In other cases the breathing may be rude or puerile. 

Special types have been considered under measles, pertussis, etc. 
Abt (following Holt, Carmichael, Ashby and Wright), offers the follow- 
ing pathological classification, which "undoubtedly gives the clearest 
basis for an understanding of the physical findings: (a) In capillary 
bronchitis there is no sign of consolidation in any part of the lung. Sib- 
ilant rales, coarse and fine crepitant rales are distributed over one or 
both lungs. The sibilant rales are due to congestion and swelling of the 
mucous membrane of the larger and smaller tubes. A feeble respira- 
tory murmur indicates areas of congestion, (b) In disseminated 
bronchopneumonia, which is characterized by small areas of consolida- 
tion, percussion usually gives negative results, though sometimes there 
is very slight dulness. The vocal fremitus is usually not altered. As a 
rule the consolidated areas are situated deeply in the lung, or are too 
small to cause any appreciable difference in the percussion note. Aus- 
cultation reveals crepitant rales and bronchovesicular breathing over 
the consolidated areas. Vocal and crying resonance is exaggerated, 
(c) In acute generalized bronchopneumonia, the percussion note is dull 
over a large area. Even an entire lobe may be involved. Palpation 
shows an increase in vocal fremitus. Auscultation reveals bronchial 
breathing, and fine moist rales are heard over the dull areas, while the 
rest of the lung shows evidence of bronchitis. " 

Issues. — Death may occur from carbonic acid narcosis, irritability 
passing into apathy, the harassing cough becoming less marked and 
causing stagnation of bronchial secretion in the large tubes ("suffoca- 
tive catarrh"); delirium develops, the pupils narrow, and Cheyne- 
Stokes breathing and heart failure result. Complete resolution is the 
rule in cases which recover. Delayed resolution with remissions and 
exacerbations may occur. Complications may develop ; (a) pleurisy is 
the most frequent ; (b) gangrene; (c) abscess, especially in aspiration 
and influenza forms; (d) pulmonary induration; (e) bronchiectasis; 
(/) tuberculosis, which is less often a sequel than a previous disease 
awakened by the new infection; (g) pericarditis, endocarditis, otitis, 
emphysema, and fibrinous bronchitis are other possible complications. 

Diagnosis. — Reliance on physical signs alone leads to many errors 
and a diagnosis is often determined by the development of sudden high 
fever or mild fever suddenly rising during bronchitis, by dyspnoea, 
irregular rapid respiration, cyanosis, and pain in the chest. In very 
young or marantic children and in the aged the onset and symptoms 



BRONCHOPNE UMONIA 519 

may be very atypical. Lobar pneumonia (q.v. variations in children) 
occurs mostly in sound children over three years of age, runs a shorter 
cyclical typical course, ends by crisis, is unilateral and involves the 
greater part of one or more lobes; while bronchopneumonia occurs 
more often in younger weakly children, is often a sequel of bronchioli- 
tis, runs a longer, more atypical, unfavorable and relapsing course, re- 
solves by lysis, is bilateral and is less marked by definite pulmonary 
findings. Tuberculosis is often distinguished only by the course; it 
invades the upper lobes more than does bronchopneumonia, and 
bacilli-laden sputum may be recovered by washing the stomach or by 
swabbing the throat when the child raises mucus after coughing. 
Pleurisy (q.v.) is diagnosticated by means of the aspirating needle. 

Course and Prognosis. — The course may be (a) acute, lasting about 
a week, of which the measles-pneumonia is the prototype; (b) 
subacute, lasting from two to eight weeks, exemplified by the pertus- 
sis-pneumonia, or (c) chronic, covering months, as in tuberculous bron- 
chopneumonia. 

The prognosis depends on the patient's social situation, previous 
history, age, the disease of which the pneumonia is a complication, 
and the extent of the pneumonia. The outlook in general is serious, 
especially in secondary forms, among which measles and pertussis 
represent the more serious types; in the very young it is almost as 
fatal as infantile diarrhoea; aspiration forms are very serious, as are 
those in marantic and aged subjects. In private practice the death- 
rate ranges from 10 to 33 per cent., in hospitals 33 to 50 per cent., 
and in asylums even higher (50 to 100 per cent.). Early cyanosis, 
dyspnoea and rapid pulse are unfavorable signs. 

Treatment. — 1. Prophylaxis. — (a) In infections which produce nasal 
or pharyngeal inflammation the nose and throat should be frequently 
cleaned with mild alkaline antiseptics. (6) When there is laryngeal or 
bronchial inflammation, congestion and atelectasis should be avoided 
by frequent and regular change of posture, (c) Deep breathing should 
be encouraged in older subjects, or enforced in the young by affusions 
of cold water on the neck and upper thorax, (d) Exposure should be 
avoided, especially at night by pinning the bedclothes or firmly fasten- 
ing the nightgown to the foot of the bed. 

2. Therapy. — Actual treatment is symptomatic, as the varied etiol- 
ogy precludes specific therapy, (a) The patient should have plenty of 
fresh air. The temperature of the room should be maintained at 67° 
to 70° with constant moderated ventilation, (b) The diet should be 
fluid, diluted or predigested; egg albumin, milk and plenty of water are 
indicated. At the onset or during the course calomel gr. rb every 
hour for five or six doses should be given, followed by castor oil, particu- 
larly if there is indigestion or tympany, (c) Expectorants, as ammonium 
carbonate, tartar emetic or ipecac, should not be given generally, as 
they derange digestion, and good digestion is of great importance to 
weak as well as to strong subjects. Aromatic spirits of ammonia, ttjk 
v to xx, every three or four hours, is least deranging and is a diffusive 



520 DISEASES OF THE RESPIRATORY TRACT 

stimulant, (d) Pain rarely necessitates the use of opiates, which pro- 
mote stagnation of secretion; dyspnoea, pain, restlessness, cough, 
cyanosis, and rapid pulse may be relieved by paregoric, which is prefera- 
ble to Dover's powder or morphine; but great care is imperative in the 
use of any opiate in young, old, or weak subjects, (e) Local applica- 
tions, as poultices or pneumonia jackets and blisters, are useless. (/) 
In the treatment of fever, antipyretics, aconite, antimony and other 
cardiac depressants should be wholly avoided. Cool applications are 
equally efficacious; they also lessen tympany and carbon dioxide nar- 
cosis, stimulate the heart and brain centres, and deepen the respiration. 
A cold pack should be applied over the neck, chest, and abdomen and 
should be changed frequently. Cold must be used with care in very 
young and in marantic subjects; in such cases a warm sponge or bath 
may be given, during which cold water may be poured on the neck to 
stimulate deep breathing, (g) For cardiac stimulants, whisky and 
brandy may be given in daily doses of 5 ss to 5 iij , very well diluted in 
water or in peptonized milk. Aromatic spirits of ammonia, digitalis, 
Saline infusions or enemata, camphor or strychnine (gr. 400 every three 
or four hours for a child six months old) may be used. Hypodermics 
of ether may cause sloughing. (h) Respiratory stimulants include 
tr. belladonna (ttjj.L to ii. every two to four hours), oxygen, thoracic 
faradization and mechanical compression of the chest, (i) Emetics 
are unreliable ; ipecac and similar remedies have no effect when there 
is pronounced carbon dioxide intoxication, whence it has been recom- 
mended to combine them with coffee, camphor, or cognac. For car- 
bon-dioxide intoxication phlebotomy should seldom be practised, (j) 
Inhalations of steam {v. Diphtheria and Croup) may be beneficial; 
compound tincture of benzoin and sodium bicarbonate are often 
added to the vaporizing water, (k) During convalescence fresh air or 
a sojourn in the country or in a warm climate is advisable, 



INDURATIVE PNEUMONIA, LUNG CIRRHOSIS, 
FIBROID PHTHISIS. 

Definition. — An (almost invariably) secondary overgrowth of the 
pulmonary connective tissue. 

Etiology. — 1. Diseases of the Lung. — These may induce local, lobu- 
lar or lobar, unilateral or bilateral fibrous induration. Local indura- 
tion frequently occurs about tumors, 'parasites, tubercles, gummata, 
abscess, gangrene, trauma, or pneumokoniosis, and is of no essential 
clincial importance, except as it demarks dangerous foci of disease. 
Diffuse induration is important, though decidedly subordinate to the 
causal disease, (a) Fibrinous pneumonia sometimes (Charcot) results 
in lobar induration; Fraenkel observed it seven times in 1,000 cases; 
it occurs notably in marantic or aged subjects and results from delayed 
resolution and lack of regeneration of the alveolar epithelium; the 
lung becomes airless and dense from development of fibrous tissue 



INDURATIVE PNEUMONIA, LUNG CIRRHOSIS, FIBROID PHTHISIS 521 

within the alveoli whence it involves contiguous structures ; its surface 
on section is smooth, and the connective tissue is strikingly translu- 
cent; slight induration may be noted in a lobe from repeated attacks of 
pneumonia. Subacute induration may begin within two or three weeks 
and reach considerable development in one or two months, (b) Bron- 
chopneumonia (Legendre and Bailly, 1844) in the course of measles, 
pertussis, or influenza, sometimes leads to subacute or chronic indura- 
tion, which may begin from an alveolitis or peribronchitis, (c) Foreign 
bodies and aspiration pneumonia; (d) chronic tuberculosis; and (e) 
syphilis, gangrene, actinomycosis, and glanders are etiological factors. 

2. Bronchial Affections. — (a) Bronchiectasis, which was noted by 
Corrigan, who was first to use the term lung cirrhosis; (b) bronchial 
stenosis, as by aneurysm, or gumma; and (c) pneumokoniosis , and 
putrid and chronic bronchitis, may cause indurative pneumonia. 

3. Pleural Affections. — The relation of pleurisy to lung cirrhosis is 
still disputed; some consider it primary to lung induration and others 
hold it secondary. It seems established that primary pleurisy may 
sometimes invade and cirrhose the lung; this is the "pleurogenous 
interstitial pneumonia" of Charcot; strands of connective tissue run 
into the lung and approach and fuse toward the hilum. 

Other causes are uncertain. English writers mention a "fibroid 
tendency," which is probably not a real cause; diabetes, alcoholism 
and malaria are also referred to as possible etiological factors. 

Pathology. — The pathology of an affection with such numerous 
causes can scarcely be described. The early induration is reddish, and 
the older connective tissue is darker, slate colored or gray; to them 
Charcot gave the names of induration rouge and induration grise, 
respectively. The new connective tissue may be formed in the bronchi, 
septi, alveoli, bloodvessels or pleura. The alveoli nearly always show 
hyperplasia of the connective tissue. The lung is airless and dense; 
is cut with difficulty and on section presents either a granulated or a 
smooth surface, the latter in cases following lobar pneumonia and 
sometimes in those consecutive to gangrene or aspiration pneumonia. 
The volume of the lung is decreased. Its shrinking produces changes 
in the mediastinum, heart, diaphragm and sound lung, which will be 
considered under Symptoms. 

Symptoms. — Incipient or localized lesions are usually undetected 
unless they are observed in the course of pneumonia or tuberculosis. 
Symptoms may be inseparable from the causal affection (tuberculosis, 
bronchiectasis) or may follow closely upon it (pneumonia, pleurisy). 
There may be a low fever, cough, dyspnoea on exertion, pain in the 
side, rapid pulse, cyanosis, ansemia, malnutrition, and night sweats. 
In cases where the original malady has ended, there may be only 
slight cough, or some shortness of breath on exertion. 

Physical findings of the typical chronic case are as follows: (a) 
On inspection the interspaces are found narrowed on the affected side, 
the nipple and scapula are nearer to the median line, the shoulder is 
lower, the spine is convex toward the sound side, and the measurement 



522 DISEASES OF THE RESPIRATORY TRACT 

is unilaterally decreased. In left-sided induration the lung retracts 
from the heart, leaving its pulsation more widely exposed and dis- 
closing the pulmonary artery, over which may be seen and felt its 
systolic filling and the strong diastolic closure of the pulmonary 
valves; in right-sided induration the heart beat may appear to the 
right of the sternum or may be covered up by the compensatory 
emphysema of the left lung, (b) Palpation corroborates these findings, 
and, as a rule, shows increased vocal fremitus. The second pulmonic 
tone is much accentuated, corresponding to the hypertrophy of the 
right ventricle and the occasional atheroma of the artery, (c) Per- 
cussion elicits dulness below and sometimes a slightly hyperresonant 
note above the indurated area; the apex of the upper lobe is on a lower 
level and the diaphragm stands higher (the liver rising or Traube's 
space increasing) ; there is no respiratory excursion, (d) Auscultation 
brings out the absence of breath sounds below, and bronchial breath- 
ing, and subcrepitant, crepitant, and bubbling rales above. Additional 
signs result from the right heart hypertrophy and dilatation and from 
coincident bronchiectasis, or cavity formation on the same side, and 
the well developed compensatory emphysema on the opposite and 
otherwise healthy side. There is nearly always some sputum. 

Diagnosis. — Diagnosis is more easily made in the very chronic than 
in the subacute forms; subacute post-influenzal or post-pneumonic 
induration may easily suggest tuberculosis, or interlobular suppura- 
tion. Slow-growing tumors of the lung may cause confusion. 

Prognosis. — The prognosis varies with the etiology. Ulcers may 
form from arterial occlusion or from infected bronchial secretion, 
whence the frequency of lung hemorrhage (in 50 per cent.) and its 
occasional role as a cause of death. Amyloidosis sometimes results, 
but death is usually caused by right heart failure, which may possibly 
occur during some acute intercurrent disease. v 

Treatment. — Therapy is unavailing, though life may be prolonged 
for decades under proper hygiene. Exercises with the arms may check 
the early shrinking, but nothing can remove an established induration. 
Warm climates at the sea level or at slight elevation are beneficial. 
Some writers hold that turpentine is of benefit in checking induration. 



PNEUMOKONIOSIS. 

Zenker employed the term to include various indurative diseases of 
the lungs due to "dust" inhalation. 

Etiology and Pathology. — 1. Anthracosis is due to inhalation of 
carbon, coal dust, soot, charcoal or graphite, and is known as "coal 
miner's disease." (a) Moderate amounts of carbon inhaled into the 
trachea and bronchi are absorbed by the leukocytes, are worked up- 
ward by the ciliated epithelial cells and are expectorated. Individual 
tolerance varies greatly, (b) Larger amounts penetrate the bronchial 
mucosa and lodge in the connective tissue, or enter the lymph stream 



PNE UMOKONIOSIS 523 

whence they reach the small lymph nodes around the bloodvessels, the 
bronchi, the pleura, or the mediastinal lymph glands. A moderate 
amount of lung pigmentation occurs in all city inhabitants, while the 
lungs of countrymen are pink and devoid of soot deposit. It is possible 
that the lymph nodes may later throw out some of the pigment into the 
bronchial lumen, (c) Very large amounts may reach the alveoli. In 
these cases the lungs are ink-black. When they are, as it were, satura- 
ted, connective tissue proliferation develops (endoperialveolitis nodosa 
and endoperilymphangitis fibrosa) in insular foci; this is sometimes 
called fibrous bronchopneumonic induration because of its localization; 
it occasionally measures 5x15 cm. ; on section the foci are hard and 
exude an inky fluid. Diffuse induration is common. The mediastinal 
lymph glands are indurated, and the process often extends outside the 
glands (perilymphadenitis) ; by this latter process the glands may 
become adherent to and rupture into the pulmonary veins, whence pig- 
ment-metastases into the liver, spleen, kidneys, and mesenteric glands 
are not infrequent. Bronchial perilymphadenitis may also lead to 
mediastinopericarditis, to stenosis of the trachea, bronchi, oesophagus, 
cava, vena azygos, and pulmonary artery, to oesophageal diverticulum, 
to fatal hemorrhage into the pericardium or into the bronchi when 
the aorta is also eroded, to aspiration pneumonia by intrabronchial 
rupture or to vagus or recurrent laryngeal paralysis by pressure. 

2. Siderosis pulmonum (Zenker) is a very similar change, due to 
inhalation of mineral dusts, as those of iron, brass, or bronze; there are 
the same interstitial deposit, lung induration, bronchial gland cirrho- 
sis, and metastases. The irritation is greater, the nodes are more fre- 
quent and the induration is more intense than in anthracosis. The iron 
deposits are yellow or red from the oxide, or black from the phosphate. 
The lungs may contain 1J per cent, of iron. 

3. Chalicosis pulmonum (Peacock) is due to inhalation of alumina, 
quartz or sandstone, and is known as "stone-cutter's or mill-stone- 
maker's phthisis," "grinder's rot" or "potter's asthma." Inhalation 
of calcium is less irritating than of silica or quartz. Of all forms, the 
most nodules and the maximal induration occur in chalicosis. 

4. Similar changes are observed from inhalation of wool, flax, 
cotton, grain, tobacco, glass, porcelain, cocoa, pepper, cinnamon, bone, 
and horn. Claisse and Jossue place special stress on bacterial coopera- 
tion. 

Symptoms. — These may appear only after many years, when the 
symptoms of chronic bronchitis, asthma, emphysema, and finally of lung 
cirrhosis appear. The sputum contains coal dust, soot, charcoal parti- 
cles, as in Traube's celebrated case, and yellow oxide or dark phosphate 
of iron, quartz, and silica. Cavities may form from bronchiectasis, 
from softening of the nodose indurations or from tuberculous complica- 
tions; in some cases lung stones, set free by ulceration, may be raised. 
The mediastinum may be exposed by retraction of the lungs, due to 
fibrous mediastinitis. Tuberculosis is common, occurring, according 
to Phillip, in 13 per cent, of anthracosis and in 44 per cent, of chalicosis. 



524 DISEASES OF THE RESPIRATORY TRACT 

Scissor-grinders rarely live beyond forty years of age and those em- 
ployed in blasting mines usually succumb in four years. 

Treatment. — Treatment is largely prophylactic and is that of the 
concomitant bronchitis and emphysema. 

ATELECTASIS. 

Atelectasis is a congenital or acquired "absence of air." It is also 
called apneumatosis. 

Congenital Atelectasis. 

1. The congenital atelectasis, first described by Joerg (1834), who 
differentiated it from pneumonia, is the persistence of the normal foetal 
condition of the lungs ; it develops in various forms of dystokia, and in 
weakly or premature infants. 

Etiology and Pathology.— This variety is due to deficient inspira- 
tory efforts from weak muscles, insufficient stimulation of the medulla 
centres, and aspiration of mucus or meconium. The base, lower 
anterior margin, and lingual lobe are most involved and the distribution 
is lobular. The color of the lung is a steel-blue, and if the subject 
lives, the atelectatic portions do not become pigmented, for no air 
enters them. The airless areas are superficial, sunken, lax, do not 
crepitate, and sink when put in water; in the early stage the part can 
be distended by inflation of the bronchus supplying it and on section 
exudes a serous or slightly blood-stained fluid. Cylindrical and cystic 
bronchiectasis may result; the ductus Botalli and foramen ovale are 
usually patent, the right heart is commonly dilated and thrombosis is 
frequent in the brain sinuses, kidney, and right heart. 

Symptoms. — The new-born who have atelectasis, breathe super- 
ficially and cry but little. Inspiration is marked by retraction of the 
epigastrium, subclavicular and intercostal spaces, for the lungs cannot 
follow the inspiratory distention of the thorax. If the undistended 
area measures 2 by 5 cm. it may be dull and increased fremitus with 
bronchial breathing may be detected, but more often the breathing is 
weak or entirely absent. Carbon dioxide narcosis develops, the pulse 
becomes small, the sensorium becomes dulled and, without active 
intervention, asphyxia with spasms causes death. If the patient lives, 
the chest is peculiarly deformed, its lower parts being sunken, so as to 
show the ribs. Koestlin describes a total collapse of one lung in a man 
aged twenty-two. 

Treatment. — Removal of meconium and mucus by swabbing or 
aspiration through a catheter, Silvester's artificial respiration, Schultz's 
swinging, faradization, and warm baths with cold affusions to the neck 
and upper chest are indicated- 



ACQUIRED ATELECTASIS 525 



2. Acquired Atelectasis. 

Acquired atelectasis in children was first described by Legendre and 
Bailly (1844), and that in adults by Traube. 

Etiology. — It may be due to marantic causes, to obstruction or 
compression; the lungs, already distended and ventilated, collapse and 
the air contained is absorbed, (a) The marantic form occurs in indi- 
viduals reduced by typhoid, infantile diarrhoea or cachectic conditions, 
and by lying for a long while in the dorsal decubitus, (b) Obstructive 
collapse develops most frequently in capillary bronchitis (broncho- 
pneumonia), as the bronchioles in the young are disproportionately 
narrow; it may develop in all conditions which promote laryngeal, 
tracheal, or bronchial stenosis. These forms affect the posterior parts 
particularly, (c) Compressive apneumatosis follows compression by 
cardiovascular conditions (aneurysm, dilated heart, and exudative 
pericarditis), by pulmonary tumors, pleural exudates or pneumothorax, 
by mediastinal tumors or adenopathies and by abdominal distention 
(tumors, ascites or meteorism). The part of the lung involved de- 
pends on the direction of the compression. In kyphoscoliosis perma- 
nent compression of the lung frequently leads to atelectasis, and if 
it occurs early in life, to hypoplasia. 

Pathology. — Pathologically the same general findings obtain as in 
the congenital type. The lung is generally darker, red-brown or bluish. 
Bronchiectasis may develop after a time. In the congenital and 
acquired types, hyperemia may cause a flesh-like appearance (carni- 
fication), or serous transudation may cause a spleen-like aspect (splen- 
ization). There may be coincident inflammation or, in the healthy 
parts, vicarious emphysema. Long-standing atelectasis results in fatty 
degeneration of the alveolar epithelium and hyperplasia of the inter- 
alveolar and interinfundibular connective tissue, known as collapse 
induration. 

Symptoms. — Symptoms are easily obscured by pleural effusion, and 
by the causal bronchopneumonia, with whose foci it may be confused. 
Inspiratory retraction, lessened vesicular breathing, a slightly tym- 
panitic note from relaxation of the collapsed lung, and crepitant rales 
are common. The vocal fremitus is seldom increased, and bronchial 
breathing is uncommon, unless the foci are both large and superficial. 
Dilatation of the right heart is common. In recent cases the physical 
signs disappear after a few hours of change of posture, or after deep 
breathing either voluntary or induced by cold affusions; this, with 
absence of fever, pain, and cough, serves as an effectual differentiation 
from infarct, pneumonia, or effusive pleurisy. After one has slept 
for some hours on the back, a few crepitant rales may be heard over 
the lower posterior parts for three or four inspirations; this is quite 
physiological. 

Prognosis and Treatment.— The prognosis and treatment vary 
according to the cause. Sudden death is not uncommon in persons 



526 DISEASES OF THE RESPIRATORY TRACT 

having deformed spines. In all fevers, as typhoid, and in all respi- 
ratory inflammations, the posture must be changed; orders to this 
effect should be written, and the change should be recorded on the 
history sheet. Cold affusions to the neck, Brand's hydrotherapy and 
cardiac stimulants are indicated. 



ABSCESS OF THE LUNG. 

Suppuration is not a common lesion, but may occur in a sound or 
diseased lung. 

Bacteriology. — The staphylococcus is most frequently the causative 
microorganism; the streptococcus, pneumococcus, pneumobacillus, 
influenza bacillus, colon bacillus, and leptothrix are also found. 

Etiology. — (a) Lobar pneumonia causes 62 per cent, of the cases 
(Tuffier) ; localization in an upper lobe, alcoholism, marasmus, pneu- 
monia complicating emphysema and lung induration, and hemorrhagic 
types are the predisposing factors; abscess of the lung is somewhat 
analogous to the necrosing interstitial pneumonia in cattle and horses. 

(b) Lobular pneumonia may suppurate, especially in the influenzal type. 

(c) Aspiration pneumonia is causal in 18 per cent. (Tuffier), partic- 
ularly in insane or delirious persons; foreign bodies, food, saliva, pus 
from lesions in the upper respiratory tract, severe vomiting, oesophageal 
cancer or diverticulum rupturing into a bronchus, are its usual causes. 

(d) Embolic suppuration produces 17 per cent, of the cases, (e) 
Trauma is an etiological factor. (/) Abscess may complicate other 
pulmonary or bronchial affections, as tuberculosis, glanders, actino- 
mycosis, echinococcus, or bronchiectasis, (g) Rupture into the lung 
of contiguous foci of suppuration, such as empyema, suppurating peri- 
bronchial glands, subphrenic abscess, spinal caries, and gastric ulcer, 
is the cause of 3 per cent, of lung abscesses. Most of the cases occur 
in middle-aged males. 

Pathology. — The cavity varies from the size of a hazelnut to that 
of an orange; in rare instances it may occupy an entire lobe or lung. 
The abscess is usually single, except in the embolic form. Its shape 
is irregular and it is sometimes multilocular. Its inner surface is 
irregular with floccular mural shreds, and is walled with pus-secreting 
granulations, which in some cases may fill and obliterate the cavity. 
Fibrous tissue develops about the cavity, and in chronic abscess be- 
comes dense and scar-like. The cavity is usually near the lung's 
surface, whence the frequency of complicating pleurisy; 80 per cent, 
of lung abscesses are in a lower lobe (Tuffier). 

Symptoms. — The development of symptoms varies according to 
the causal factor; in lobar pneumonia the crisis or lysis is delayed, 
and resolution is incomplete; in influenza the respiratory symptoms 
and fever persist; in sepsis, multiple lung involvement perpetuates 
the septic process, (a) The sputum is purulent, creamy, is often 
offensive or rancid without putridity, is alkaline and may measure a 



ABSCESS OF THE LUNG 527 

pint to a quart daily. It separates, on standing, into two layers, a 
granular sediment and a serous upper layer, sometimes with frothy 
surface if the coughing is intense. In metapneumonic cases the 
sputum is sometimes grass-green. The sediment almost invariably 
reveals shreds of lung tissue (Traube and Leyden), and yellowish- 
green or gray flocculi; these are absolutely essential to diagnosis, 
and consist of elastic fibers to which alveolar epithelium adheres. 
Hcematoidin crystals or platelets, short sheaths of fatty crystals, bac- 
teria (v. s.) } and in chronic cases cholestearin and scar-like connective 
tissue are also found. The sputum is voided periodically, as from 
cavities of other causation; " mouthful expectoration" is the rule, (b) 
The decubitus varies with the location of the cavity; for instance, the 
patient assumes the erect posture if the cavity is in a lower lobe, to 
prevent leaking of the secretion into the contiguous air passages, (c) 
Signs of cavity are found if the exulceration is large and superficial; 
80 per cent, of them occur in the lower lobes. They are essentially 
those of tuberculous or bronchiectatic cavities (q. v.) and vary with the 
stagnation or evacuation of the pus ; thus a tympanitic note, bronchial 
or amphoric breathing, and increased vocal fremitus are found when 
the vomica is empty, and dulness, weakened breath sounds and de- 
creased fremitus are present when it is full. The arrays also serve to 
localize, but when their findings and the physical signs differ the latter 
are more trustworthy, (d) Hectic fever, sweats, rigors and leukocy- 
tosis occur from resorption. 

Diagnosis.— The etiology and cavity formation are often, and the 
sputum is always, characteristic, (a) Abscess breaking into the lung 
from the spine, or from the subphrenic or pleural spaces, is sudden, 
sometimes suffocative in onset, and the hsematoidin crystals and shreds 
of pulmonary tissue are absent. (b) Gangrene (v. i.) is a factor in 
differentiation, (c) Tuberculosis usually occurs in an upper lobe; 
abscess in a lower one; elastic fibers and hcematoidin crystals are more 
abundant in cases of abscess, and tubercle bacilli are found in tuber- 
culosis, at least after several examinations, (d) In cases of bron- 
chiectasis elastic fibers are seldom voided. 

Prognosis. — Spontaneous recovery may follow granulation and 
cicatrization, especially in lobar pneumonia, where recovery is the 
rule. In influenzal or aspiration pneumonia or in sepsis, the out- 
look, is far less favorable; marasmus, hectic fever, amyloidosis, 
lung induration, empyema, pneumothorax and pericarditis are fre- 
quent issues. 

Treatment. — (a) The general strength should be maintained by giv- 
ing a full diet, tonics, and alcohol, (b) Decomposition, if present, 
should be modified as in bronchiectasis or gangrene, by administra- 
tion of creosote or turpentine internally, (c) Surgical intervention is 
indicated, according to Fraenkel, (i) when the abscess is large, shows 
no tendency toward spontaneous cure and the contents decompose; 
(ii) when rupture into the pleura occurs; and (iii) when the abscess 
results from the breaking into the lung of a contiguous focus of sup- 



528 DISEASES OF THE RESPIRATORY TRACT 

puration. Of Korte's 12 operative cases, 83 per cent, recovered; in 
Garre's 96 cases, 80 per cent.; in Tuffier's series, 77 per cent.; in 
Freyhan's acute cases, 90 per cent. ; and in his chronic cases but 14 
per cent. 

(G). GANGRENE OF THE LUNG. 

Definition. — A necrosis and mortification of lung tissue. Gangrene, 
though more common than abscess, is an infrequent affection; Eich- 
horst found gangrene in 0.1 per cent, of his clinical cases and Hensel 
in 1.6 per cent, of his autopsies. 

Bacteriology. — Some physicians maintain that certain germs pro- 
duce the necrosis and other germs the gangrene, but others hold that 
one microorganism may produce both changes. The staphylococcus 
is found in its various forms, also the streptococcus, colon bacillus, and 
pseudotubercle bacillus which retains its stain when treated with 
acids like the bacilli found in putrid bronchitis and bronchiectasis ; the 
Bacillus pyocyaneus, and the Micrococcus tetragenus are also found ; 
Hirschler and Terray have cultivated a micrococcus which liquefies 
gelatin and produces skatol and indol, and therefore causes a putrid 
odor in the cultures. Babes described bacilli resembling those of 
malignant oedema. The leptothrix, oiidium albicans, spirilla, sarcinae 
and monads are probably of but secondary importance. 

Etiology. — Decidedly reduced physiological resistance, e. g., from 
diabetes, is apparently a necessary etiological factor. Lobar pneur 
monia may terminate in gangrene when, as in abscess, the patient is 
weakly, diabetic, addicted to alcohol or suffering from putrid bron- 
chitis; its frequency is not great, for it occurs in but 0.4 per cent. 
(Fraenkel) or in less than 1 case in 1,500 pneumonias (Aufrecht); 
pneumonia causes 23 per cent, of lung gangrene (Coupland and Hen- 
sel). Lobular pneumonia is less frequently causal, though grippal 
pneumonias may terminate in gangrene (7 per cent, in FraenkeFs 
series). In Coupland and Hensel's combined cases, 14 per cent, were 
due to pulmonary tuberculosis, and 10 per cent, to tumor of the lung. 
Gangrene may complicate lung abscess or echinococcus. Aspiration 
pneumonia resulting in gangrene occurs particularly in insane, deliri- 
ous, paralyzed, or emaciated subjects; foreign bodies, necrotic dis- 
eases of the throat or bronchi, laryngeal perichondritis, bronchiectasis, 
putrid bronchitis, and bronchial stenosis promote gangrene. Embolic 
gangrene, a cause of 19 per cent, of lung gangrene, may result from 
suppurative gangrenous lesions in peripheral parts, as in or about the 
appendix, uterus, or extremities. Rupture into the lung, as of oesoph- 
ageal cancer or diverticulum, putrid pleurisy, subphrenic abscess, or 
gastric ulcer may cause gangrene. Trauma is an occasional promot- 
ing factor. Gangrene usually occurs within the second to fourth de- 
cades of life and chiefly in males. 

Pathology. — Genuine gangrene must not be confused with soften- 
ing of the lung, which is due to regurgitation of the gastric juice into 



GANGRENE OF THE LUNG 529 

the lung during the death agony or after death. In rare cases, too, a 
non-putrid pneumomalacia, analogous to myomalacia cordis, is ob- 
served. Lung gangrene, according to Hensel, occurs in the right 
lung in 45 per cent., in the left in 37 per cent., and in both lungs in 
18 per cent, of the cases. Laennec, who first described pulmonary 
gangrene, distinguished two types, the circumscribed and the diffuse, (a) 
Circumscribed gangrene occurs chiefly in the lower lobes and toward 
the surface, rarely in the interior and oftener on the right than on the 
left side. The focus may attain the size of an orange. Laennec dis- 
tinguishes three stages, (i) The formation of a yellow, green or 
brown slough, which may be expectorated entire; (ii) liquefaction, or 
moist gangrene; and (hi) formation of a cavity which is irregular in 
shape, has ragged walls, and contains a stinking liquid resembling the 
sputum of gangrene (y. i.). The cavity may be limited by granulations 
and later by connective tissue, or may gradually extend, corroding more 
and more lung tissue. Extension may also result from aspiration of the 
septic matter from the bronchi into other lung areas. Recovery may 
follow localization, organization of granulations, and contraction of 
connective tissue. Microscopically there is (i) an inner zone of offen- 
sive fluid or necrotic tissue, bacteria and emigrated leukocytes; (ii) 
outside of this is a zone of granulations, beyond which is (iii) congested 
or cedematous lung. (6) The rarer diffuse gangrene has no demarka- 
tion, and a large area, an entire lobe, or even the whole lung may be 
macerated, stinking and discolored. The diffuse form occurs more 
often in the upper lobes, and in the right more frequently than in the 
left side. In both forms the sputum irritates and injects the bronchial 
mucosa, the bronchial glands are usually tumefied and degeneration or 
metastasis may occur in various viscera. 

Symptoms. — 1. The sputum is characteristic; its presence is almost 
absolutely essential to a diagnosis, and it is absent only when the putrid 
focus has no bronchial connection. Its odor is extremely offensive, 
faecal, stinking, garlicky, or sometimes sweetish. This odor is less 
marked in diabetic gangrene; it is most offensive at the moment of 
evacuation, and on standing may gradually lessen. The sputum, 
which is voided periodically, and sometimes in mouthfuls, is usually 
abundant (a pint to a quart), is alkaline, and on standing separates 
into three layers, an upper layer of foam, a middle one of green or 
gray serum, and a lower one of green or brownish granular sediment. 
In the sediment various important structures are found; there are 
flocculi of lung tissue, which are seen best against a dark background, 
and which vary in size from small particles to pieces as large as the 
thumb and show alveolar arrangement; elastic fibers are not nearly 
as common as they are in abscess of the lung, unless the process is 
very acute, for a trypsin-like ferment rapidly digests the fibers; Dit- 
tricKs plugs are usually found, consisting of detritus and bacteria, 
and emitting a most fcetid odor (described under Putrid Bronchitis 
and Bronchiectasis); long fatty needles (Virchow), lung pigment, pus 
cells, red corpuscles, haematoidin, bacteria, infusoria, triple phosphates, 

34 



530 DISEASES OF THE RESPIRATORY TRACT 

leucin, tyrosin, formic and other allied acids, phenol, indol, skatol, 
ammonia and sulphuretted hydrogen are also found. 

2. Chest findings. — Besides the findings of bronchitis caused by 
the offensive sputum, signs of infiltration or cavity formation are ob- 
tained if the focus is superficial and measures two and a half inches. 
In the common circumscribed form the signs of cavity are identical 
with those in tuberculosis, bronchiectasis or abscess, i. e., a tympanitic 
note, increased vocal fremitus, bronchial or amphoric breathing, and 
metallic rales are obtained when the cavity is empty, or dulness, de- 
creased fremitus and weak breathing, when it is full. In the rare 
diffuse form there are signs of infiltration as in pneumonia, which 
signs are also found in the initial stage of the circumscribed gangrene. 
Pulsation of the gangrenous lung is very rare. The a>rays are often 
valuable in detecting the localization of the gangrene. The patient 
lies so that the cavity is dependent, in order to avoid constant trickling 
of the cavity secretion into the bronchi, i. e., on his back when it is 
posterior, or on his face when it is anterior or in an upper lobe. 

3. General symptoms result from the causal disease or from sepsis. 
Remittent fever, chills, sweats, prostration, emaciation, pallor, rapid 
bounding pulse, anorexia, vomiting, diarrhoea, leukocytosis, albumin- 
uria and in severe cases a profound typhoid state mark the degree 
of intoxication. 

4. Complications may dominate the clinical picture, (a) Pleurisy 
(in 12 per cent.), usually purulent or putrid, may be one of the chief 
symptoms, and operation may evacuate most offensive fluid with large 
fragments of necrotic lung, (b) Haemoptysis is seldom fatal though 
frequently profuse, and the blood raised may be dark brown, (c) 
Pyopneumothorax, or id) rupture into the thoracic wall, oesophagus, 
aorta, mediastinum, pericardium, or peritoneum may occur, (e) There 
may be metastatic deposits in the brain, liver, joints, or muscles. (/) 
Clubbed fingers occasionally result from septic absorption, (g) Amy- 
loid degeneration of the liver, spleen and kidneys sometimes results 
from chronic gangrene. 

Course and Prognosis. — The course may be acute, subacute or 
chronic; in general it is more rapid in diffuse (usually fatal within a 
week), and more chronic in circumscribed forms (weeks to even three 
months). The prognosis depends on the etiology, the physical strength 
of the patient, the degree of absorption, localization and surgical 
accessibility (v. Therapy). 

Diagnosis. — Exploratory puncture is dangerous, for it favors dif- 
fusion, (a) In factor ex ore the breath is foetid but the sputum, 
if any, shows no characteristic findings of gangrene, (b) In putrid 
bronchitis the sputum shows Dittrich's plugs and fcetor, but no fatty 
crystals, elastic fibers, nor pulmonary tissue, (c) In abscess elastic 
fibers and pus are more abundant, the fatty crystals are oftener in 
sheaths than in long needles, and hsematoidin crystals are more com- 
mon; bronchial plugs or fcetor are absent, (d) In bronchiectasis elastic 
fibers are very rare and lung tissue has never been found, (e) In 



TUMORS OF THE LUNG 531 

tuberculosis coincidence of the two affections and the pseudotubercle 
bacillus (v. Tuberculosis) may alone cause confusion. 

Treatment. — 1. Surgical.— Expectant treatment results in a mor- 
tality of 53 per cent. (Eichhorst) to 80 per cent. (Lenhartz). In 15 
personal cases (a small number), 10 (66 per cent.) recovered under 
medical treatment. With operative treatment Turner gives the death- 
rate in 72 cases as 40 per cent., and Freyhans in 26 cases, 30 per cent.; 
Garre in 122 cases records 66 per cent, of recoveries and 34 per cent, 
of fatalities. The indications for treatment are (a) the vital indication 
when acute gangrene assumes the joudroyant type, or (6) when, in 
chronic forms, there is no tendency toward spontaneous healing. Bull 
reports recovery even in multiple gangrene. Accurate localization by 
physical findings or by the arrays, is of course conditional and was 
possible in 65 per cent, of Tuffier's series of 74 cases. 

2. Expectant Treatment. — This is indicated in deep-seated gan- 
grene, in hopeless metastases as those of the brain, or in apparent 
demarkation. The patient should be kept on his back to avoid 
leakage into sound bronchi. The diet should be sufficient to support 
the strength and should include full alcoholic stimulation. Carbolic 
acid, balsam of Peru or creosote may be given internally. Turpentine 
is most efficacious when there is a complicating hemorrhage (Skoda). 



TUMORS OF THE LUNG. 
1. Carcinoma. 

Cancer of the lung may be primary or more often secondary to 
that of the mamma, or of the digestive or genital organs. It occurs in 
0.17 per cent, of autopsies or in 1.8 per cent, of cancer autopsies 
(Paessler, quoted by Fraenkel). Most primary cases develop between 
forty and sixty years of age. In primary forms the sexes are equally 
involved though Paessler found 73 per cent, in males; the secondary 
forms are frequent in women. 

Etiology. — Trauma is an uncertain factor. Cancer usually develops 
in the bronchi, in which previous ulceration, syphilis or adherent and 
rupturing lymph glands are predisposing factors. Carcinoma probably 
may develop from the bronchial mucous glands or even from "the alveo- 
lar epithelium. Histologically the cylindrical type is by far the most 
frequent, though medullary, scirrhous and other forms may be encoun- 
tered. Cancer usually begins at the hilum, and may extend toward 
the pleura, either by contiguity along the bronchi or by the lymph 
spaces. The upper lobes are more often involved than the lower ones, 
and the right twice as frequently as the left. The disease is generally 
unilateral. In 85 per cent, of cases metastases occur in the liver, 
bones, brain, mediastinum, testes, and kidney. Secondary cancer 
is generally bilateral; the lungs are strewn with miliary nodules 
resembling miliary tuberculosis, or present numbers of larger nod- 



532 DISEASES OF THE RESPIRATORY TRACT 

ules. Calcification and ossification may occur in tumors of the 
lung. 

Symptoms. — When there is a primary accessible tumor in another 
part of the body, the appearance of cyanosis, dyspnoea, blood-stained 
sputum, and signs of lung infiltration or of cavity, facilitates a diag- 
nosis of lung metastasis. When there is a hidden primary focus or 
a primary lung tumor, diagnosis is often for a long time difficult or 
impossible. 

1. Early General Symptoms. — These are usually ambiguous; they 
are suggestive of tuberculosis, pleurisy, or bronchitis, all of which may 
indeed complicate neoplasm. Thoracic oppression, asthmatic attacks, 
stridor and dyspnoea result from pressure on the trachea and vagus 
or wide substitution of tumor for lung tissue. Cyanosis, dyspnoea, 
rapid breathing, fever, emaciation and sweats may suggest miliary 
tuberculosis ; this resemblance may also be noted at autopsy in miliary 
carcinosis. Fever is, however, not common. Actual pain is usually 
pleuritic. Cough is common. 

2. Sputum. — The sputum in over 50 per cent, of cases is rather 
characteristic, though it may show similar changes in tuberculosis and 
other affections. Altered blood gives it a reddish-brown color. It 
may resemble raspberry jelly in hue and in consistency; it is some- 
times grass-green or prune-juice in color. Occasionally macroscopic 
and microscopic bits of cancer tissue, in characteristic nest-like arrange- 
ment, are seen. 

3. Physical Signs. — (a) Inspection: the patient usually lies on 
the affected side to give freer play to the sound lung. Marked 
ectasia may result; sometimes the diseased side is shrunken from 
complicating lung cirrhosis or atelectasis. Unilateral retraction with 
other signs indicates bronchial stenosis, (b) Palpation elicits increased 
fremitus if the tumor grows into the bronchial lumen or compresses it 
from without, (c) Percussion gives an irregular dulness, increasing 
to absolute flatness, in outlining which the finger perceives greatly 
increased resistance; it most often occurs over an upper lobe or under 
the sternum, (d) Auscultation varies with the patency of the bronchus, 
giving bronchial breathing when it is open and weak or absent breathing 
when occluded. 

4. Compression Symptoms. — Besides the early dyspnoea and cough 
(v. s.), (a) the heart is often luxated or its yielding auricles are 
crowded, (b) The venous trunks suffer compression with frequent 
cyanosis and oedema of the face, neck and arms and with dilatation 
of other veins of the thorax, due to formation of a collateral circula- 
tion, (c) There is compression of the vagus, with rapid or slow heart, 
and recurrent laryngeal compression with phonic changes, (d) 
Dysphagia, (e) intercostal neuralgia and brachial neuralgia or par- 
alysis, and (/) tracheal or bronchial stenosis are other symptoms of 
compression. 

5. Metastasis. — This occurs in 85 per cent, of cases; there may also 
be extension, by contiguity, to the axillary or cervical glands. 



SARCOMA AND LYMPHOSARCOMA 533 

» 

6. Complications. — These include haemoptysis from necrosis and 
cavity formation; gangrene and bronchiectasis; and pleurisy, which 
is usually serous; hemorrhagic effusions occurred in 12 per cent, of 
Moutard Martin's 200 cases; the fluid may resemble venous blood; 
adipose or chyliform effusions are rare; hydropic, fatty and granular 
cells may be obtained by puncture, and Hellendall advises aspiration 
for flocculi of tumor tissue, with the syringe and needle partly filled, 
with salt solution, before aspiration. Carcinomatous nodes may de- 
velop at the site of puncture, though hard nodules at the site of tapping 
not infrequently occur after puncture of simple pleuritis and ascites. 



2. Sarcoma and Lymphosarcoma. 

Sarcoma and lymphosarcoma may be primary or secondary, and are 
more frequent than cancer. They probably begin chiefly in the lymph 
nodes of the bronchi, and oftener on the left than on the right side. 
Extension in all directions occurs along the peribronchial tissues from 
the hilum. A primary very malignant lymphosarcoma develops in the 
lungs of miners in the cobalt mines of Saxony; it causes 75 per cent, 
of the deaths among them; secondary sarcomata in the liver are com- 
mon. Ulceration is less common than in cancer, but the symptoms 
are, in the main, identical. Sarcomatous tissue is occasionally voided 
in the sputum or aspirated by the exploring needle. The diagnosis of 
malignant lung tumors must be made chiefly from aneurysm (q. v.) 
and pleurisy (q. v.). The arrays may be of some value. There are 
three main clinical groups, (a) in which a neoplasm, perhaps its exact 
type, can be diagnosticated; (6) in which some growth is present but 
differentiation from aneurysm is uncertain; and (c) in which the dis- 
ease entirely escapes detection or is only suspected. 

Prognosis. — Death generally occurs in less than a year with cachexia 
or suffocation, but it may result in a few weeks after the first symptoms 
appear. 

Other Tumors of the Lung. 

Other tumors, as fibroma, lipoma, osteoma, or enchondroma are of 
solely anatomical interest. 

Treatment. — The treatment of tumors of the lung is only palliative. 
Morphine must be used when the dyspnoea and cough are extreme. 
The arrays offer little encouragement. Arsenic seems to help when 
given in full doses. 



534 ^DISEASES OF THE RESPIRATORY TRACT 

CIRCULATORY AFFECTIONS OF THE LUNG. 
1. Acute Congestion. 

As a secondary lesion acute hyperemia commonly occurs with 
acute tuberculosis, pneumonia, influenza, effusive pleurisy, perhaps 
rheumatism, with inhalation of hot vapors or air, or with cardiac strain ; 
when extensive lesions occur in the lungs the obstructed blood may 
seek other parts of the lungs and possibly produce collateral congestion, 
though this is justly disputed. French writers describe an acute 
primary congestion to which they give the name of Woillez (Maladie 
de Woillez), though it was previously described by Dechambre, Legen- 
dre, Bailly and Fournet. Its status as an independent lesion is doubt- 
ful; some cases are apparently larval or abortive pneumonia which 
occurs in any large epidemic. According to Carriere it is due to atten- 
uated pneumococci, which he has demonstrated by puncture of the 
lung. Cold, exposure, alcoholism, and violent exertion are alleged 
causes. It develops like pneumonia, with chill, fever of 101° to 103°, 
pain in the side, dyspnoea, cough, and a sputum which is at first scanty 
and later is more abundant and viscid but not blood-stained. Physical 
examination is said to elicit somewhat impaired resonance, weak or 
occasionally bronchial breathing, rales which are coarser than in pneu- 
monia and at times a pleural rub. All these symptoms and signs 
strongly suggest atypical fibrinous pneumonia. Venesection and vaso- 
dilator remedies, as aconite or veratrum, are said to be of benefit. 



2. Passive Congestion; Hypostasis. 

In broken compensation, particularly in mitral stenosis, the lungs are 
distended, heavy, indurated, pigmented, and on section are brownish- 
red; this is brown induration (induratio pulmonum fusca). Histologic- 
ally the capillaries are turgid, the connective tissue is increased, the 
lungs are tinged with altered blood pigment, and the sputum contains 
the so-called heart cells (See Symptoms of Valvular Disease.) The 
breathing is sometimes puerile and the lung voluminous. 

Hypostasis is a species of passive congestion which results from 
weak heart, as in typhoid and other fevers, in old age, cachexias, mar- 
asmus, in opium and other narcoses, or in apoplectic and other comas. 
Even under these conditions it rarely occurs if the patient's position 
is changed every few hours. The lung is dark red, engorged with 
blood and serum, and may also show aspiration pneumonia and 
atelectasis ; the latter conditions are often incorrectly called hypostatic 
pneumonia. On physical examination, there is moderate dulness over 
the lower lobes posteriorly; in apoplexy this may occur only on the 
paralyzed side; the breathing is more often weak than bronchial, 



INFARCT; EMBOLISM 535 

and moist (sometimes crepitant) rales are heard. Fever is no part of 
hypostasis. 

Treatment. — Treatment of passive congestion is that of the funda- 
mental lesion; phlebotomy, cardiac stimulation or even aspiration of 
the right ventricle in broken compensation and in hypostasis, frequent 
change of posture, and cardiants, are indicated. 



3. Infarct; Embolism. 

Etiology. — Embolism was first observed by Laennec; Virchow, 
Cohnheim and Litten established its pathology. The most frequent 
source of lung embolism is (a) fibrinous coagula from the right heart, 
the frequency and mechanism of which have been discussed under 
Acute and Chronic Endocarditis (mitral stenosis) and Septicaemia. 
Clots may also reach the lung from peripheral or * peri-uterine throm- 
boses, and are either simple (i. e., non-suppurative, marantic) or 
inflammatory and septic. Rarer causes are (b) tumor or hepatic tissue, 
(c) fat embolism after fractures, and liver injury, (d) air embolism or 
(e) parasites (echinococcus cysts). 

Pathology of Infarction. — The embolus may obstruct a main branch 
of the pulmonary artery, straddle one of its secondary bifurcations, 
or lodge in a smaller vessel. Not every embolism produces an infarct, 
for instantaneous death may occur, the occlusion may be incomplete, 
or collateral circulation may be possible. Occlusion of an end vessel 
results in the hemorrhagic infarct, which is often wedge-shaped 
with its base toward the pleura, is dark at first and later lighter, is 
airless, on section projects above the cut surface, often measures 
2 to 6 cm., and is attended by extravasation of blood into the lung 
cells and sustentacular tissue, though the lung is not torn. This is 
known as a fibrinous or simple infarct. If the embolus contains pus 
or putrefactive microorganisms, it develops into abscess or gangrene. 
Infarcts occur oftener in the lower than the upper lobes and more 
frequently on the right than on the left side. They are often multiple. 
Small infarcts may be wholly absorbed, but the larger ones leave pig- 
mented cicatrices. 

Symptoms. — (a) Infarction of the main pulmonary trunk may re- 
sult in immediate death, as sudden death from sitting up after child- 
birth. In other cases death occurs in a short time from cerebral 
anaemia attended by convulsions, dyspnoea, and cardiac failure. The 
infarct may cover the greater part of the lobe involved ; if the patient 
lives for some time, a sudden systolic murmur may develop over the 
pulmonary artery (Litten). (b) Infarction of a smaller vessel is often 
ushered in with chill, vomiting, dyspnoea, cyanosis and fever, even 
with bland embolism. The sputum contains dark blood and there is a 
"stitch in the side" from pleural participation. Physical examination 
frequently elicits a pleural rub and later, in some cases, slight dulness, 
especially behind, between the spine and scapular line; crepitant rales 



536 DISEASES OF THE RESPIRATORY TRACT 

and bronchial breathing are frequently present. Pyogenic or putrid 
clots cause abscess, gangrene, empyema, or pneumothorax. 

Diagnosis. — Diagnosis is often at best a probability diagnosis. 
Sudden cardiac failure is very difficult to differentiate from an embolic 
occlusion of a main pulmonary trunk, especially when death occurs 
without haemoptysis. The etiology, the sudden onset and circum- 
scribed chest signs are of diagnostic importance. Treatment lies 
solely in cardiac stimulation. 



4. (Edema of the Lungs. 

Etiology. — In the etiology of this secondary, common, frequently 
terminal or agonal affection, three important causes stand in the fore- 
ground, viz., heart, kidney and lung disease. (Edema consists of the 
pouring out into the air cells and interstitial tissue of a serous trans- 
udate. A precise classification of the mechanism of pulmonary 
oedema is difficult: — (a) Stasis due to weakened heart is probably its 
most frequent mechanism. Cohnheim and Welch demonstrated ex- 
perimentally that it may result from failure of the left ventricle whereas 
there is continued activity of the right ventricle; this may be com- 
mon in the death agony, but the explanation is not entirely satisfactory, 
as cases of pulmonary oedema occur in which the pulse (and therefore 
the action of the left ventricle) is strong; however, general cardiac 
anasarca may occur when the radial pulse is apparently sufficiently 
strong, though it is known that the heart must be weak. Grossmann 
advances the theory that there is a spasm of the left ventricle. Weak 
heart may result from any disease of the endo-, myo-, or pericardium. 
Sahli explains certain cases by (b) paralysis of the pulmonary vessels. 
Under either (a) or (6), nephritic oedema or the toxic cedemas, such as 
those from the iodides, ether, pilocarpine or muscarin, may be in- 
cluded, (c) Inflammatory oedema, such as that around a fibrinous 
pneumonia and numerous other pulmonary diseases, cannot be strictly 
brought under oedema, for it is an exudation, not a transudation. 
However, in this form the pulse is usually strong, and there is often 
fever, (d) Angioneurotic oedema is sometimes described. It is also 
possible that (e) occult changes in the blood and bloodvessels are causal 
factors. These varied mechanisms, though generally stated to be 
most common in cardiac, renal, and pulmonary lesions, may also oper- 
ate in cachexia, anaemia, cerebral disease, old age, and innumerable 
other conditions. 

Pathology. — Pathologically oedema may be circumscribed or oftener 
diffuse. The lungs are large, heavy and spongy; they pit, and on 
section, especially of the bases, a frothy, serosanguineous fluid exudes. 

Symptoms. — Symptoms usually come on precipitately, with hurried 
breathing, dyspnoea, cyanosis and carbon dioxide intoxication. The 
sputum is copious, foamy, serous, somewhat resembling soapsuds, or 
at times is tinged with blood ; it is rich in albumin and poor in mucus 



HAEMOPTYSIS 537 

and cells. The bubbling breathing indicates serum in the alveoli. 
The second pulmonic sound is accentuated, the pulse is weak, the lung 
note is slightly tympanitic from relaxation, and coarse and fine rales 
are heard everywhere. If the lower lobes are filled, the physical signs 
may closely resemble those of consolidation, i. e., there may be in- 
creased fremitus, bronchial breathing and dulness. The diagnosis 
is determined from the sputum and lung findings. 

Treatment.— Treatment may be beneficial in some cases, though too 
often oedema is the death agony itself, (a) Prophylaxis concerns the 
causal disease, for example, cardiac weakness, or anasarca, in cases 
of nephritis, (b) Rapidly acting, diffusive stimulants are urgently 
indicated hypodermatically, as camphor, ether, strophanthus and 
strychnine, and coffee or champagne by mouth, (c) Morphine with 
atropine is at times almost specific, (d) Venesection relieves the right 
heart and therefore the lungs, (e) Stimulating expectorants, as senega 
and rapid purgation by crotin oil, TTjjiij, on the tongue, are sometimes 
of value. The author has obtained no results from the acetate of 
lead, which is recommended by Traube in doses of gr. ss to i every 
hour or two, and by Nothnagel in a single dose of gr. x to xx. 



5. Haemoptysis. 

Haemoptysis or haemoptoe refers to "spitting of blood," while pro- 
fuse hemorrhage is known as pneumorrhagia. 

Etiology. — (a) Laryngeal ulceration or inflammation; (b) tracheal 
ulceration or aneurysm bursting into the trachea; (c) severe inflam- 
mation or ulceration of the bronchi, stasis from cardiac disease, 
bronchiectasis, putrid and fibrinous bronchitis, rupture into the air 
passages of aneurysm or anthracotic lymph glands, and thermal, 
chemical or mechanical irritation are etiological factors; haemoptysis 
may also occur in the acute exanthemata, in such affections of the 
blood as haemophilia, scurvy, purpura haemorrhagica, and leukaemia, 
and in gout, renal disease and cholaemia; haemoptysis occurring as 
vicarious menstruation was mentioned by Hippocrates, and though 
rare, is an established variety; vicarious haemoptysis after ovariotomy 
or suppression of hemorrhoidal bleeding is still more uncommon and 
its existence has been regarded with just scepticism, (d) Lung disease 
is the most important etiological factor, and the chief lesion is (i) tuber- 
culosis, (q.v.), which causes 80 to 90 per cent, of cases of blood-spitting. 
It is commonest between the fifteenth and thirtieth years, and very 
rarely occurs under six years of age, as children seldom develop cavi- 
ties. As stated under tuberculosis, it occurs as capillary or profuse 
hemorrhage. It was noted long ago that haemoptysis sometimes occurs 
rather epidemically among tuberculous cases; in such an outbreak, 
Flick, Ravanell and Erwin found the pneumococcus in the sputum, 
(ii) Infarcts are usually characterized by haemoptysis, (iii) Pneu- 
monia, abscess and gangrene; (iv) tumors; (v) parasites of the lung, 



538 DISEASES OF THE RESPIRATORY TRACT 

echinococcus, filiaria, gregarina, distoma and actinomycosis; and (vi) 
syphilis and leprosy, are more uncommon causes, (e) Haemoptysis 
nervosa is most rare, though authentic cases have occurred in cerebral 
traumatism, hysteria (where it has caused death), epilepsy and in 
some other neuroses. (/) A toxic hsemoptoe may occur from mercury 
or iodide, but it is very rare. 

Symptoms. — Symptoms may follow those of the causal disease, as 
tuberculosis, mitral stenosis, or aneurysm, or they may develop in 
apparent health. Haemoptysis is in itself only a symptom. Blood 
poured out into a cavity or into the lung substance is not always 
voided, especially in very weak or moribund persons. Prodromes are 
unusual ; without other warning, sl salty taste in the mouth, substernal 
warmth, a sense of something rising from the chest, and coughing, are 
followed at once by a few spoonfuls or more of blood. At times a 
previously mucous sputum may be accidentally noted to be blood- 
stained. The blood varies in amount from the merest stain to 5 quarts 
(Laennec); it may appear but once or may recur several times. It 
is generally bright red and well mixed with air; the formation of 
rouleaux is uncommon. If the blood has clotted in the lung or air 
passages, the clot, too, is mixed with air and perhaps with mucus. 
Casts of the bronchioles may be voided. If there is gangrene or abscess, 
the blood may be brown or buff-colored and the red cells may be 
disintegrated. Brown hemosiderin granules, or, if the blood has 
remained in the clot two weeks, hsematin crystals may occur. Asthma 
crystals are occasionally seen. 

Physical findings, other than those of the fundamental condition, 
are frequently lacking; if the blood obstructs a fairly large bronchus, 
there may be bronchial breathing, bronchophony, increased fremitus, 
and dulness if the affected area measure 2 by 5 cm. In the bronchioles, 
blood gives rise to small rales, in the bronchi to coarser rales. 

Complications. — Fever, aside from the causal disease, may result 
from resorption (ferment fever). Urobilin icterus, functional heart 
murmur, relaxation of the right heart, albuminuria and puffiness of 
the ankles are possible but not conspicuous complications. 

Diagnosis. — Examination of the nose, gums, throat and larynx 
readily excludes hemorrhage which may simulate hsemoptoe. It is 
often difficult to distinguish at the time of bleeding between arterial 
and capillary or between bronchial and pulmonary bleeding, but the 
question may be decided by the history, by later physical examination 
and by the clinical evolution. 

H.E MATEMESIS . VS . BLe MOPTYSIS . 

(a) The blood is acid (unless a very Is alkaline 
large amount is voided). 

(6) The patient nearly always recognizing whether it is vomited or coughed up. 
(Blood from the lung is very rarely (Haemoptysis, very rarely, causes con- 
swallowed and then vomited.) sensual vomiting.) 



HEMOPTYSIS 539 

(c) Is often dark (though large amounts Nearly always bright (though when 

of bright red blood may be vom- stagnating in a cavity it may become 

ited, as in ulcer). dark or buff). 

(d) Is mixed with food, HC1, ferments, Mixed with air, which is also found in 

etc. the clots. (Not infrequently tubercle 

bacilli, heart cells, etc., are found.) 

(e) In 10 to 15 per cent, of cases blood Is very rarely in stools. 

is in the stools. 

Prognosis and Course. — The duration is variable, but spontaneous 
cessation is the rule. The immediate prognosis is good, as early- 
death from hemorrhage is rare, except in cases of profuse pneumor- 
rhagia, resulting, for instance, from aneurysmal rupture, and even 
here the patient may live years after the aneurysm has broken into 
the lung substance. Drowning or suffocation of the patient in his 
own blood is rare. The final outcome depends on the etiology. In 
Ware's 386 cases, 16 per cent, recovered. 

Treatment. — Prevention. — In tuberculosis (q. v.) the patient should 
be kept quiet, the cough should be suppressed and exertion and vocal 
efforts should be avoided; in heart disease and marantic thrombosis, 
rest is indicated to obviate detachment of the thrombi. 

Therapy. — Absolute physical and mental quiet should be enforced 
when haemoptysis occurs. No movement should be allowed ; coughing 
should be suppressed by hypodermatic injections of morphine, which 
also allay the attendant mental excitement (opiates are not to be 
employed in cases of very large hemorrhages, for bronchial occlusion 
may result). The patient should be assured of a favorable outcome; 
no physical examination should be made except auscultation of the 
chest in front, and this should be done only if necessary, for immediate 
treatment takes precedence of diagnosis ; if rales indicate which side 
the hemorrhage is on, the patient should lie on that side to prevent 
aspiration into the contralateral bronchus. 

Arterial pressure should be reduced by administration of aconite or 
veratrum, which lessen tension in both the pulmonary and arterial 
circulation. A liquid, simple, spare diet should be given. Alcohol, 
coffee, tea, strychnine, and digitalis should be interdicted. Even if 
the patient collapses cardiants should be avoided, for syncope is 
nature's readiest haemostatic; the old custom of venesection in this 
way promoted thrombosis. Cardiac excitement is lessened by placing 
a large ice-bag over the precordium. Active purgation by croton oil 
is very beneficial. 

Hemostatics are not proven to control the lesser blood circuit, 
which appears to be rather independent of drugs which operate on 
the arterial circuit. Ergot, if anything, rather raises the blood pressure 
in the lungs and should therefore seldom be given. Calcium chloride 
gr. v to x, and common salt on the tongue are of some value (salt 
acts reflexly, by way of the vagus, on the pulmonary vessels) . Gelatin 
(2 per cent.) may be used in urgent cases and the beneficial effects of 
turpentine have long been known. Nature, as a rule, effects the cure; 



540 DISEASES OF THE RESPIRATORY TRACT 

drugs do not, though opiates reinforce nature. Hippocrates employed 
ligature of the extremities, i. e., binding tightly for a few minutes 
the vessels of the groin and axilla, in order to lessen the return flow of 
blood toward the point of hemorrhage. Artificial pneumothorax, to 
compress the bleeding lung, has been advocated in cases of desperate, 
profuse and persistent haemoptysis. 

PARASITES OF THE LUNG. 
Echinococcus of the Lung. 

Man may become infected with the tinea echinococcus from dogs 
by their licking their master's hands or from faeces contaminating 
human food, especially vegetables. The unilocular form is much 
more common than the multilocular. Infection occurs either (a) 
primarily, the embryo skipping the liver, or (6) much more often 
secondarily, by metastasis or breaking through the diaphragm from 
the liver. According to Neisser's figures from 900 cases, 50 per cent, 
occurs in the liver, 9 per cent, in the kidneys, 8 per cent, in the cran- 
ium and 7 per cent, in the lungs. The small miliary white cysts may 
grow to the size of an adult's head. They may calcify, indurate, sup- 
purate, putrify or rupture into contiguous parts (See Animal 
Parasites). 

Symptoms. — Many cases produce no symptoms and are unex- 
pected findings at the post mortem. Dieulafoy described three clinical 
stages: — (a) the initial, (b) the tumor stage and (c) the suppurative 
or rupture stage, (a) The initial stage often has no symptoms, but 
may be marked by scanty capillary haemoptysis, cough, emaciation 
and possibly fever, all of which may closely simulate incipient phthisis. 
(b) In the tumor stage, there is bronchial (or weak) breathing, increased 
fremitus and circumscribed dulness, which occurs in the lower lobes 
and twice as frequently on the right side as on the left; it sometimes 
causes bulging of the chest wall. There is a sharp transition between 
it and the note of the sound contiguous lung. Dislocation of the heart, 
compression of the lung and other luxations may occur. The arrays 
often confirm the physical signs. The dulness curves upward, but 
is quite different from the curve of pleuritic effusion which is concave 
upward. Tumor of the lung gives a larger, harder flatness. Puncture 
(v. i.) reveals a clear, aseptic fluid of 1,009-15 specific gravity with 
little or no albumin, very rich in sodium chloride and the characteristic 
succinic acid; the inosite is of no practical importance; the hooklets 
are pathognomonic, (c) In the stage of suppuration or rupture, as 
in liver echinococcus, rupture may occur into the pleura (in which 
primary disease is 25 times as rare). Pneumothorax may result. Far 
oftener rupture into a bronchus occurs, with pain, dyspnoea, collapse, 
and sudden "mouthful" expectoration of pus, small vesicles, lamel- 
lated cyst wall and hooklets. At the time of rupture a curious urticaria 



Dl STOMA OF THE LUNG 541 

develops (Finsen) which is probably toxic as the fluid from echino- 
coccus cysts produces it when inoculated into animals. Profuse 
haeruoptoe is common. If it comes from the liver, the sputum is ochre- 
yellow from undissolved bilirubin, even when there is no direct con- 
nection with the bile vessels; cholestearin is often present. The 
vesicles or cyst wall may cause suffocation. Rupture may also occur 
into the pericardium, stomach, or peritoneum. In this stage hectic 
fever is usual. 

Diagnosis. — Diagnosis is determined only from the sputum, or from 
puncture which has decided dangers, as sudden, probably toxic death 
is a common sequel. 

Prognosis. — The course varies much. A cyst in two or three months 
becomes as large as a hazelnut, and in five months as large as an 
orange (Dieulafoy). Death may result from suffocation, hemorrhage, 
gangrene, hectic fever or toxaemia from rupture or puncture. 

Treatment. — If puncture is made, and is followed by severe symp- 
toms, the case should be instantly operated. There is no medical 
treatment. Without surgical intervention 57 per cent. (Hearn) to 66 
per cent. (Davaine) die. Tufher and Garre* report but 10 per cent, 
mortality with operation. 



Distoma of the Lung. 

This affection was first described by Baelz in Japan, Formosa and 
Corea. The worm is plump, wide, egg-shaped, measures 8 to 10 x 4 
to 6 mm., is brownish red and is provided with two small suckers. 
Its eggs are oval, brown and measure 0.08 to 0.1 x 0.05 mm. Little 
is known of its origin. It is found in the bronchi and in the infarcts 
and cavities which it produces. The cavities contain red disks, a 
mucoid substance and shreds of lung tissue, and are surrounded by 
fibrous tissue. The parasite is also found in the liver, diaphragm, 
mesentery and brain. The course of the disease is chronic, though 
most cases terminate favorably; it is marked by (a) bronchitic symp- 
toms, (6) haemoptysis and (c) a viscid clear sputum in which minute 
brownish-red dots, the distoma eggs, are seen. In exceptional cases 
death results from emaciation, exhausting haemoptysis or brain em- 
bolism. 

Tuberculosis, syphilis, and actinomycosis of the lung are described 
under Infections. 



542 DISEASES OF THE RESPIRATORY TRACT 

DISEASES OF THE PLEUBA. 

(A). PLEURISY. 

Definition. — Pleurisy is an inflammation of the pleura, rarely pri- 
mary but usually secondary to tuberculosis or other lung disease, general 
infections, septicsemic affections and various diseases in contiguous 
tissues or organs. 

Pleurisy constitutes about 3 per cent, of internal maladies and is 
the most common of all post mortem findings (in over 50 per cent.). 
It is susceptible of division into infinite varieties, acute, subacute or 
chronic according to its course, dry or effusive according to its con- 
sistence, primary or secondary as to its cause, diffuse or circumscribed 
as to its distribution and serofibrinous, hemorrhagic or suppurative 
as to its nature. Any such classification is more or less artificial, 
whence it seems preferable to describe first all its symptoms and group 
special types later. 

Etiology. — 1. Tuberculosis. — So-called primary, spontaneous or 
cryptogenetic pleurisies are often tuberculous (Barrs, Netter, Lemoine, 
Vaillard, Coston and Dubville). Landouzy considers that 98 per cent, 
of all pleurisies are tuberculous and that 60 per cent, of all cases of 
phthisis pass through the so-called pleuritis a frigore; Netter holds 
that 70 to 80 per cent., and Ashoff that nearly all "primary" cases, 
are tuberculous. Thirty-two per cent, of Osier's cases were tubercu- 
lous, 32.6 per cent, of Bowditch's and 40 per cent, of Hedges cases. 
Le Damay in 55 "primary" pleurisies proved by inoculation that 92 
per cent, were tuberculous. Trauma favors development of tuber- 
culous pleurisy. The causal lesion may be recognized at autopsy in 
calcified bronchial glands or in small lung foci. Tuberculous pleurisy 
is often bilateral. Non-tuberculous pleurisy, by causing adhesions, 
may sometimes favor the development of pulmonary tuberculosis. 
Its special relations will be discussed later. 

2. Diseases of the Lung Substance. — Such diseases as pneumonia, 
abscess, gangrene, infarcts, tuberculosis, tumors, pneumothorax, echin- 
ococcus, tertiary syphilis, and actinomycosis are etiological factors; 
according to Koplik, 95 per cent, of pleurisies in children follow pneu- 
monia. It is less frequent in diseases involving the bronchi, as in 
grippe or measles. 

3. Acute Infections. — Rheumatism, sepsis, puerperal fever, endo- 
and pericarditis, variola, scarlatina, measles, diphtheria and other 
acute infections may result in pleurisy. It develops in about 2 per 
cent, of typhoid cases; it may develop in secondary syphilis without 
lung lesions (Chantemesse and Widal), probably from toxaemia. 

4. Diseases of Adjacent Organs. — (a) Intrathoracic affections, in- 
volving the ribs, spine, oesophagus, mediastinum, lymph glands, dia- 
phragm, and pericardium; (b) abdominal affections, as of the stomach, 



PLEURISY 543 

spleen, or liver (abscess, tumor, or cirrhosis [in 16 per cent.]), subphrenic 
abscess, suppurative or tuberculous peritonitis (in 25 per cent.), peri- 
nephritic abscess, abdominal malignancy, etc., may promote pleurisy; 
pleural infection may occur by direct local invasion or by the lymph 
and blood streams; in neglected appendicitis, hepatic and diaphrag- 
matic invasion occurs, followed by pleural infection. 

5. Tumors. — Echinococcus and endothelioma (Wagner and Fraen- 
kel) are the most important types. According to Neelsen, endotheli- 
oma is an infectious process, a lymphangitis prolif erans (Schwenniger) 
or according to Schottelius it is a lymphangitis carcinomatosa. The 
pleura swells and develops callosities or adhesions. Carcinoma, sar- 
coma, ecchondroma, and rarely lipoma are also factors; pleural neo- 
plasms are far more frequently secondary than primary. 

6. Altered Conditions of the Blood (Dyscrasise). — Gout, nephritis, 
scurvy, and tertiary syphilis are often causative of pleurisy; these 
conditions frequently produce bilateral pleurisy and result possibly 
from chemical products or from reduced physiological resistance, 
which predisposes toward various infections. 

7. Terminal Infections. — Various forms of sepsis are often fatal to 
subjects of chronic disease of the heart, liver and kidneys; bilateral 
pleurisy is frequent. 

8. Age, Sex, Localization. — Age: most cases occur between the 
twentieth and fiftieth year, but no person is exempt, from intra-uterine 
life to extreme old age. Sex: Eichhorst observed pleurisy in 3 per 
cent, of all his male and 2 per cent, of all his female cases, and found 
the following localization: right-sided in 54 per cent., left-sided in 42 
per cent., and bilateral in 4 per cent. Cases following nervous disease, 
cold or exposure, venous thrombosis, or trauma can usually be brought 
within the above given classification. 

Bacteriology. — The etiological classification above given does not 
correspond to the bacteriological division. Suppurative pleurisy may 
result from the streptococcus, pneumococcus, tubercle bacillus, or 
less often from the staphylococcus, or typhoid or colon bacilli; serous 
pleurisy may be due to the tubercle bacillus or to the pyogenic organ- 
isms. The frequently negative cultural results have favored the 
hypotheses that chemical products, such as retained urinary substances 
in ursemia or tuberculin in phthisis, may of themselves produce 
pleurisy, or that bacteria produce pleurisy and then die. It must be 
remembered that cultures are usually made, not from the pleura 
directly, but from the fluid effused from it. The organisms found are 
most frequently the pneumococcus, tubercle bacillus and streptococcus, 
less often the staphylococcus, pneumobacillus of Friedlander, typhoid, 
colon, influenza (in two cases only) and diphtheria bacillus, gonococcus, 
ray fungus, glanders bacillus, Micrococcus tetragenus, and Micrococcus 
pyogenes tenuis, (a) Purulent pleurisy (empyema) is most often due 
to the streptococcus in adults and to the pneumococcus in children. 
About 10 per cent, of empyema is tuberculous; empyema giving 
no results culturally or bv inoculation is usually tuberculous and may 



544 DISEASES OF THE RESPIRATORY TRACT 

be regarded as a cold abscess of the pleura (Kelsch and Vaillard). 
The staphylococcus, Micrococcus tetragenus and pyogenes tenuis, 
pneumobacillus, typhoid and colon bacilli are infrequent factors. (6) 
Serous pleurisy is usually tuberculous, as shown by the constantly 
increasing percentage of cases in which inoculations are successful. 
It was formerly stated that tubercle bacilli are not frequently found, 
and that, when found, their presence suggests a direct communication 
with a tuberculous focus in the lung or lymph glands ; negative results 
are due either to an insufficient amount of fluid (less than 10 to 20 
c.c.) being inoculated, or to the effusion being due to toxins rather 
than to the microorganisms themselves. Eichhorst found tubercle 
bacilli by direct examinations in but 15 per cent, of serous pleurisies, 
though his inoculations were positive in 62 per cent. Jousset recom- 
mended that the fluid be allowed to coagulate and the clot digested 
with pepsin, centrifuged and then stained; his method is termed 
inoscopy. (c) Most cases of so-called primary pleurisy which are non- 
tuberculous are due to Fraenkel's pneumococcus. (d) Meta- and para- 
pneumonic pleurisy is most frequently due to the pneumococcus, but 
also to the streptococcus and staphylococcus, even when no pus is 
formed, although mixed infections have a tendency to suppuration. 

Symptomatology. — Physical findings are absolutely essential for 
diagnosis and all subjective symptoms are ambiguous or may be 
wholly absent. In the main, all types have much the same signs which 
differ more quantitatively than qualitatively; serous pleurisy nearly 
always shows friction, and fibrinous pleurisy is almost always accom- 
panied by some exudation. 

Inspection. — (a) Inspiratory retraction of the intercostal spaces may 
result from imperfect ingress of air, from pain or from adhesions. 
Epigastric retraction during inspiration is due to contraction of the 
diaphragm, (b) The patient often lies at first (during the dry stage) 
on the sound side to avoid pain from pressure on the inflamed surfaces ; 
later (during the exudative stage) he lies on the diseased side in order 
to allow, for mechanical reasons, a freer expansion of the sound lung, 
especially when the exudate is large. Traube believed that continued 
lying on the diseased side aggravated pain by congesting the pleural 
and subpleural veins. The patient may sit up for breath, or assume 
the diagonal decubitus (Andral). (c) Ectasia (distention) of the 
affected side occurs especially in children, and is determined by men- 
suration and inspection. The interspaces are obliterated, the costal 
arch is immobile during respiration, the skin glistening, the spine 
curved toward the diseased side, the shoulder higher and the nipple 
and scapula are further from the median line. The right chest is 
normally one or two centimeters larger than the left; again, the sound 
side usually measures three centimeters more than its normal dimen- 
sions (or more than the diseased side) on account of compensatory 
emphysema (Gerhardt and Kerlias). In some cases of very large 
effusions the writer has observed an apparent retraction of the dis- 
eased side, (d) Respiratory movement of the affected side is de- 



PLEURISY 545 

creased or absent in both dry and exudative pleurisy. Respiration is 
reflexly decreased on the diseased side, and at times occurs somewhat 
later than on the sound side, i. e., the breathing lags on the diseased 
side. The frequency of respiration is increased from lung compres- 
sion, pain, heart luxation, the low diaphragm, fever or oedema and 
paresis of the intercostal muscles. Pain alone may reflexly decrease 
the respiratory expansion, and variation on the same side may occur, 
there being more movement above and less below, (e) The #-rays 
often, but not always, show a dark shadow. (/) Inspection also reveals 
cyanosis, oedema of the chest wall (in suppurative pleurisy and oc- 
casionally in other forms), dislocation of the apex beat, substernal 
pulsation, venous pulsation; (g) absence of Litteri's 'phenomenon 
and (h) rarely pulsation of the effusion, (i) C. L. Greene describes a 
rhythmic lateral displacement of the heart peculiar to pleurisy: "Such 
movement is most marked in medium-sized effusions. The heart 
approaches the affected side in inspiration and moves outward in 
expiration. The extent of movement is variable, but often amounts 
to two inches. It may be measured by fluoroscopic examination, 
auscultatory percussion, or, in the case of right-sided effusions, by 
simple deep percussion of the free cardiac border, or in some instances 
by mere inspection of the apex beat. Deep breathing, and especially 
forced expiration, are essential to the success of the maneuver, and to 
obtain this morphine must sometimes be administered. Marked 
rhythmic lateral movement has not been found by the writer in pneu- 
monia, tuberculous infiltrations of the lung, malignant disease of the 
pleura or lung, or in subdiaphragmatic abscess." 

Palpation. — Palpation confirms the findings of inspection, (a) An 
up and down (less often horizontal) friction rub is felt; it increases 
on pressure, which also increases the pain and tenderness, and it is 
the more readily distinguished the coarser the rub and the more capable 
the chest wall of vibration. It is usually absent in obese individuals. 
The friction develops before the effusion, is often present with it, and 
after it is absorbed. The rub is due to roughening of the pleura, 
which loses its glistening appearance and looks like glass upon which 
one has breathed (Klebs); the two raw pleural surfaces scrape on 
each other. It may be very transient, lasting a few hours or days, or 
even disappearing when the patient takes a deep breath; or it may 
last for months, or even years. (6) Pressure on a tender interspace 
during deep inspiration may cause a sudden contraction of the upper 
part of the rectus muscle on the side of lesion (Schmidt), (c) Vocal 
fremitus, normally greater on the right than on the left side, varies 
according to the level at which it is tested, (i) Above the effusion it 
is normal, (ii) Near the spine, over the compressed and relaxed 
lung it is increased, (hi) Below, it is weak or absent, from exudation 
of thick fibrin or fluid, though less change is observed in dry pleurisy 
than in the effusive form. Irregular findings are due to the presence 
of adhesions bringing the lung closer in some places than in others 
to the chest wall. The condition of the lung and the bronchial secre- 

35 



546 DISEASES OF THE RESPIRATORY TRACT 

tion are important in diagnosis, whence before testing, the patient 
should cough and take a few deep breaths. The results are irregular 
in cases of loculated effusion, (d) By tapping with the finger tips 
the increased resistance is clearly palpated, (e) (Edema of the chest 
wall on the diseased side may be inflammatory (in serous as well as 
in purulent pleurisy), or mechanical and more intense from pressure 
on the azygos or hemiazygos veins. (/) Fluctuation is rarely palpable, 
and only in cases of great effusion. It is elicited by pressing the 
fingers of one hand upward toward the diaphragm with the fingers of 
the other hand in the interspaces, (g) Palpation also determines the 
dislocated apex beat, the dislocated liver or spleen, the bulging of the 
diaphragm and sometimes a furrow between the diaphragm and liver 
(Stokes). 

Percussion. — Percussion is negative in dry pleurisy, except when 
there is a very thick fibrinous exudate, which may cause dulness 
and weak breathing; after an effusion has resorbed, the plastic lymph 
which is left may cause dulness. When there is effusion (a) dulness 
is found between the fifth and eighth ribs in the left axilla or on the 
right side over the liver and posteriorly. Dulness may also result from 
old adhesions, atelectasis of the lung, great fibrin formation in the 
pleura, or a very thick chest wall. As in pneumothorax, distention of 
the lungs and calcification of the ribs may somewhat obscure the dul- 
ness of an effusion. In doubtful cases the apparently sound side 
should be percussed first. According to Ferber's experiments on the 
cadaver, thirteen ounces (400 c.c.) of fluid are necessary in the adult 
for recognition and four ounces (120 c.c.) in children; post mortem 
experiments, however, do not exactly fulfill the conditions obtaining 
during life. The effusion must be one inch (2 c.c.) thick to produce 
dulness. Sometimes, however, even six to seven ounces (200. c.c.) 
which produce a dulness two fingers in height, may be recognized. 
In some doubtful cases smaller amounts may be detected, as proven 
by puncture, especially in persons having thin thoracic walls, as in 
children and women. Light percussion is necessary when the effusions 
are small, lest other normal parts be brought into vibration. Before 
percussion the patient should breathe deeply several times to eliminate 
partial collapse of the lung and impaired ingress of air from accumu- 
lated bronchial secretion. Percussion is absolutely essential to diag- 
nosis. Not merely the audible dulness should be regarded, but also 
the palpable sense of resistance, on light percussion. The dulness is 
marked, and usually amounts to distinct flatness. In larger effusions, 
the flatness is at first located posteriorly, and is noticed to increase 
along the spine and also laterally in the axilla. In massive exudates, 
flatness may reach from the lower limit of the pleura to above the 
clavicles. 

The dulness is usually highest posteriorly, but adhesions may cause 
an opposite condition. The line of dulness is not even, but describes 
a parabolic curve (courbe de Damoiseau), due according to Ger- 
hardt to the uneven thickness of the chest wall or according to Eich- 



PLEURISY 547 

horst to irregular adhesions. If the fluid should effuse while the 
patient is in bed, the highest level of dulness would be in the axillary- 
line; if it should effuse when he is out of bed, the upper level would 
be horizontal. Dulness is found one to two centimeters higher than 
the upper level of the fluid, due to plastic exudate, (b) Right-sided 
effusions merge with the liver dulness, but the lower limit of left- 
sided effusions can usually be determined, because they invade Traube's 
semilunar space. This "half moon" space lies between the fifth and 
sixth costal cartilages above, and tenth rib below, representing the 
supplementary pleural space, and is designated as the "half-moon" 
space because of the curve at its upper portion, produced by the apex 
of the heart; its tympanitic note is decreased or replaced by flatness 
in left-sided effusions (without adhesions). Dulness here may not be 
confused with that of the spleen, for there is no respiratory excursion 
in pleurisy, and the dulness lies more toward the heart than toward 
the splenic region. Scybala, or food in the stomach or bowels, may 
also impinge on Traube's space, (c) Respiratory excursion is absent 
in effusions of any size, (d) The change of the upper line of dulness 
with change of position has been emphasized by Gerhardt, Rosen- 
bach, Da Costa, and by most writers. It is usually stated that change 
of position causes variation in the level of the effusion, and that the 
level changes in 55 per cent., changes very little in 30 per cent., and 
none in 15 per cent, of cases. According to personal experience, it is 
difficult to detect on account of the adhesions which are usually present 
at the level of the fluid. The line of dulness does not change rapidly 
on mere change of posture ; the patient must lie some hours in another 
posture before any alteration of the upper level occurs, (e) A vertical 
strip of tympany along the spine, often measuring three centimeters 
wide, may be detected when there is a large exudate ; it is due to com- 
pression of the lung. Tympany in the lower part of the left chest may 
result from gaseous distention of the stomach and intestines. (/) 
Tympany is observed over an upper lobe from compression or relax- 
ation of the lung. It was first observed by Avenbrugger and Skoda, 
and is usually called the Skodaic note. Rosenbach explains it by ten- 
sion of the intercostal muscles during inspiration, (g) " Cracked-pot" 
resonance occasionally appears on short forcible percussion over the 
upper lobe, and results from sudden expulsion of air through the rima 
glottidis. (h) William's tracheal note is observed on the left more than 
on the right side, and chiefly when the entire side is dull. It is obtained 
most clearly in the first and second interspaces, and is due to trans- 
mission of percussion vibration from the fluid to the trachea, giving 
a tympanitic note. A change of pitch with opening and closing of the 
mouth, like thai observed by Wintrich, in lung cavities, may some- 
times occur, (i) Grocco's sign is a small triangular dulness on the 
sound side along the vertebrae, due to compression of the healthy side 
or to dislocation of the aorta and mediastinum by large exudates, (j) 
There may be dislocation of other organs. There is no direct parallel- 
ism between the amount of exudate and the amount of luxation, 



548 DISEASES OF THE RESPIRATORY TRACT 

which, of course, is absent if the organs are adherent. The heart is 
usually dislocated in toto and but seldom suffers torsion or change of 
the direction of its axis. The right ventricle may be seen to pulsate to 
the right of the sternum, even as far as the line of the right nipple, 
when the effusion is left-sided. In right-sided effusions the apex is 
pushed to the left and downward, for the diaphragm is lower. The 
liver is less easily displaced than the heart, but in right-sided effusions 
is pushed down and the left lobe tipped somewhat upward, though both 
lobes may be dislocated downward in very extensive pleurisies (Traube 
and Fraentzel). In left -sided effusions the spleen is dislocated down- 
ward and forward, undergoes some torsion, and may stand perpendicu- 
lar to the costal arch. 

Auscultation. — This is most important in dry or effusive pleurisy. 
(a) The friction rub (see Palpation) may be hard or soft, is super- 
ficial (i.e., close to the ear), and resembles the sound made by 
scratching the finger upon the ear, or the crunching of snow under 
the shoe; it often develops in the first twelve hours. It is most fre- 
quent during inspiration, but is also very often detected in expira- 
tion ; it seldom occurs during expiration alone. Inflammation of one 
leaf of the pleura is sufficient for its production. It may disappear 
after several long breaths which smooth the pleural roughening. The 
interrupted rub is due to pleural irregularities. It may be increased 
by pressure and is subject to no law as to its duration. Wintrich 
heard a pleural rub which lasted more than four years and Gerhardt 
heard one lasting six years. It is heard most frequently over the 
anterolateral portion of the chest, and is detected more clearly with 
the stethoscope than with the naked ear, but may sometimes be heard 
at a distance of several feet as in a case seen by the writer with Dr. H. 
M. Richter. If it is apical, it is probably due to tuberculosis. It may 
also be present in miliary tuberculosis (v. Jiirgensen) and in tumors 
of the lungs or pleura without actual pleurisy. It usually becomes 
less clear when exudation develops, and its reappearance may indi- 
cate the beginning of absorption, or the extension of the process at 
the level of the fluid, (b) The breath sounds are modified not only 
by the effusion, but also by the condition of the lung, the strength of 
breathing and the conditions of conduction existing in the pleura and 
thoracic walls. In general, and especially in men and children, the 
respiratory sounds are weakened, even in fibrinous pleurisy, from 
repressed breathing, and perhaps from pain alone; cog-wheel breath- 
ing is common. In moderate effusions three zones are observed: (i) 
Absence of breathing in the lower parts from compression of the lung 
by the exudate, which lessens the conduction of the vesicular sounds; 
(ii) Bronchial breathing in the middle zone from moderate collapse of 
the alveoli of the lung, with fair conduction through the bronchi. 
(iii) An upper zone of sharp or exaggerated vesicular breathing. In 
larger effusions the lower zone extends higher and bronchial breath- 
ing may be heard near the clavicle or between the scapula and spine. 
In the largest effusions the breathing is indistinct everywhere, with 



PLEURISY 549 

areas of metallic bronchial breathing when the lung is wholly col- 
lapsed. Amphoric breathing results in exceptional cases, (c) The 
voice sounds are not heard over the fluid or over very thick, plastic 
exudate. They may persist in various places, when islets of the lung 
are adherent to the chest wall, (d) Bronchial breathing and increased 
fremitus may be present, especially in children with empyema, under 
the^following conditions : if the chest wall is not the seat of oedema, if 
the bronchi are patent, if there is no great fibrin deposit on the pleura, 
and if the lungs are retracted but not absolutely compressed. The 
bronchial breathing may sometimes be as intense as in pneumonia 
or tumor. In adults increased fremitus may be observed between 
the spine and scapula where the lung is compressed, (e) Bronchoph- 
ony depends upon the same conditions as bronchial breathing, 
viz., patent bronchi, moderate retraction of the lung and conditions 
favoring good conduction of sound. (/) Mgophony, which is an exag- 
gerated bronchophony, was described by Laennec; it is found chiefly 
in middle-sized effusions, usually at the level of the fluid. It occurs 
less often in large cavities and in infiltrations of the lung. In large 
effusions it is rare, the compression being too great. It is caused by 
the voice sounds passing through the compressed smaller bronchi to 
the chest wall; it may be present when the exudate is increasing or 
decreasing at a given point, (g) Baccelli's symptom is the "whispering 
voice/' which is heard on the diseased side; Baccelli thought that it was 
observed more often in serous effusions, but it also occurs in other forms 
of pleurisy, in chronic induration of the lungs, pneumonia, hydro- 
thorax and cavities, (h) A wide propagation of the heart tones is indic- 
ative of consolidation, rather than of effusion, but if consolidation is 
excluded, the hearing of the heart tones more widely than normal sug- 
gests dislocation of the heart by an effusion. Murmurs, which result 
from bending of the large vessels by dislocation of the heart may be 
heard, as well as accidental murmurs resulting from a weakened heart, 
from toxsemia or from high temperature. 

Diagnostic Puncture. — This determines: (a) the existence of pleu- 
risy, excluding pneumonia, hypostasis, tumor, or atelectasis; (b) 
the character of the fluid; and (c) the prognosis. It is indicated in 
all doubtful cases. Puncture with aspiration is also an important 
therapeutic measure. Negative results from puncture may result 
from a thick fibrin deposit and thick exudate, from failure to reach an 
encapsulated effusion, as in interlobar pleurisy, and from the membrane 
being pushed in before the needle so that the fluid is not reached. In 
negative or dry taps after withdrawal of the needle, examination should 
be made to see that no plug of fibrin or cells has collected in the 
needle. If a plug is obtained it should be emptied upon a glass slide and 
examined under the microscope. Care should be taken that no car- 
bolic acid or alcohol remain in the syringe or needle, which, by coagu- 
lating the serum, may cause some dry punctures. The puncture should 
be made with a large needle. Positive results: when the needle is intro- 
duced, resistance may be felt, which is due to a callous pleurisy or an 



550 DISEASES OF THE RESPIRATORY TRACT 

indurated lung. Often after introducing the needle, the point may be 
felt to be freely movable as in a cavity. Sometimes the results differ 
according to the level of the puncture; serum may in rare cases be 
obtained from a high puncture and a cellular deposit from a lower 
one; this results from the cells settling to the bottom. Again, punc- 
ture in different localities may show serum in one, and hemorrhage or 
pus in other sacs. Bacteriological examinations made with 10-20 c. c. of 
the serum give frequent results, and 60 to 90 per cent, of the serous 
cases are proven tuberculous on inoculation. The special chemical, 
bacteriological, cellular and other characteristics will be discussed 
under individual forms. 

Symptoms. — Symptoms may be absent (latent pleurisy) ; if present 
they are not distinctive and there is no fixed relation between the symp- 
toms and physical findings, (a) The temperature is variable. Its rise 
is usually gradual and a rigor, as in pneumonia, rarely occurs. For 
weeks there may be no temperature, even in purulent exudates, 
especially in marantic, diabetic and anaemic subjects and in terminal 
infections. When present it may be continuous, but more frequently 
subcontinuous or remittent. The average elevation is 101° to 102°. 
Temperature is no positive index as to the character of the fluid. 
Exacerbations of temperature are important prognostically, especially 
when the appetite is poor and no change occurs in the physical 
findings. Recovery is not to be expected until the temperature has 
been normal for some time. A sudden rise and fall, like a crisis, is 
exceptionally observed just before resorption. (b) Thepulseis increased; 
it is sometimes small and is occasionally of the paradoxical type or 
unequal in the two radial vessels, (c) Dyspnoea is seldom a part of 
pleurisy, for effusions may attain enormous proportions without respir- 
atory difficulty, particularly when they are gradual in development. 
Dyspnoea is usually referable to coincident bronchitis, pneumonia, 
lung congestion (Potain), pericarditis, arteriosclerosis, nephritis or to 
bilateral pleuritis. (d) Pain is usually an initial symptom. It is in no 
way proportional to the physical findings. It may be absent when aus- 
cultation shows a marked rub. Its character is usually dull, tearing, 
stabbing and sometimes very severe; it may be crampy or colicky. 
The pain is usually pleural (Cruivelhier) but may be neuralgic or due 
to neurotic or muscular causes. Pain is present in the diseased side, 
well down over the ribs, over the liver, epigastrium or low in the back, 
and sometimes may radiate to the sound side (Laennec and Gerhardt), 
into the arm or spine, or into the abdomen, especially in children, in 
which case it may simulate appendicitis, (e) Coughing, an early and 
frequent symptom, results from accidental bronchitis or more often 
from pleural irritation. It may occur after change of posture or after 
tapping. It is usually unproductive. (/) Other symptoms are anorexia, 
vomiting, headache, difficult swallowing due to involvement of the 
foramen wsophageum (Ferber) and marked sweating (the sweats of 
pleurisy rank next in importance after those of sepsis and rheumatism.) 
The urine is scanty but increases during resorption, when peptonuria 



PLEURISY 551 

and transient albuminuria are often found (Courmont and Nicola). 
The skin may be pale and cachectic from purulent accumulations, red 
from high temperature, cyanotic from poor oxygenation or suddenly 
pallid from hemorrhage into the pleura when there is also a sudden 
increase of fluid. Emaciation is common in chronic pleurisy of the 
tuberculous or purulent type. 

Special Forms. — I. Character of the Inflammation. — In 790 cases 
Eichhorst found serous pleurisy in 81 per cent., fibrinous in 12 per cent., 
purulent in 5 per cent., ichorous and hemorrhagic, each in 1 per cent. 

1. Serous 'pleurisy is the prototype of pleural inflammation. As 
stated, most cases are tuberculous. The fluid is lemon-colored. Its 
specific gravity ranges between 1,015 to 1,023, which Mehu con- 
siders characteristic of inflammation. Albumin is present, and 
amounts to 3 to 7 per cent.; sugar is frequently present; glycogen, 
urea, uric acid, and bile are inconstant constituents. The fluid clots 
after puncture. All varieties of pleurisy, serous and otherwise, con- 
tain white blood cells, red blood cells and endothelial cells; the cells 
may show some fatty degeneration. 

Cytodiagnosis. — -Much emphasis has been placed on the character of 
the leukocytes found in tuberculous pleuritis; Widal and Renault 
(1900) especially insisted — and later writers confirmed the statement — 
that lymphocytes are characteristic of primary pleural tuberculosis and 
afford early diagnostic data, long before the results of inoculation are 
available; the fluid must be examined before it coagulates; in other 
pleurisies the polymorphonuclears prevail; in other words, the "lymph- 
ocytic formula" indicates tuberculosis, the "polymorphonuclear 
formula" indicates pyogenic infection or pleurisy secondary to well- 
developed phthisis, and the "endothelial formula" indicates irritation, 
transudation or malignancy. The tuberculous nature of pleurisy is 
established by inoculation tests, which are positive in 50 to 66 and 94 
percent., by apical involvement or that of other serous membranes, by 
the finding of tuberculosis in cases of sudden death in the course of 
pleurisy (Lendouzy, Dujardin, Beaumetz, Dieulafoy, Kelsch, Binet), 
and by the fact that 25 to 33 per cent, of cases later become obviously 
tuberculous. It is well to suspect, at least, the tuberculous nature of 
all so-called rheumatic pleurisies {pleuritis a f rigor e), though cold may 
sometimes produce pleurisy in both man and beast. The sputum 
and lungs should be carefully watched in such cases for some time 
(See Prognosis). For the tuberculin test and Marmorek's modifica- 
tion of it see Diagnosis of Tuberculosis. The leukocytes are 
not increased in the blood count. 

2. Fibrinous pleurisy usually shows some fluid, serous or purulent, 
if systematic punctures are made. 

3. Purulent or suppurative pleurisy (empyema) usually begins as a 
serous exudate which soon becomes opaque and purulent. The sterile 
tuberculous form has been discussed (v. s. Bacteriology). The most 
frequent types are (a) the streptococcic form, which is observed chiefly 
in adults, in which the fluid is thin and separates on standing into an 



552 DISEASES OF THE RESPIRATORY TRACT 

upper serous layer and a lower denser layer, in which fibrin 
formation is slight; and (6) the pneumococcic form, which is more 
common in children, in which the fluid is more homogeneous and viscid, 
like the "laudable" pus of the early writers, in which the fibrin and 
membrane formation is abundant, and the odor peculiar; it is 
more often accompanied by endocarditis, pericarditis and meningitis, 
and is more often febrile and more susceptible of spontaneous recovery 
than the streptococcic form. Over 80 per cent, of juvenile empyemas 
are pneumococcic. The fact that the pneumococcus has far less pyo- 
genic properties in the lung than in the pleura, has excited frequent 
comment. Microscopically, various bacteria are present (v. Bacteri- 
ology), polymorphonuclear and often fatty white cells, and sometimes 
cholestearin and Charcot-Leyden crystals. The distention of the chest 
may be enormous; Krause reported 22 pounds of pus in one case. 
Leukocytosis and hectic fever are mentioned under symptoms. 

Empyema pulsans (Walshe) is not frequent; 95 per cent, of all 
pulsating effusions are purulent, while but 5 per cent, are serothorax; 
93 per cent, are left-sided. A pulsating tumor as large as the fist may 
be noticed, which usually, but not always decreases during inspiration, 
or the effusion may simply pulsate behind the ribs; in either case the 
pulsation may be expansile. The pulsating tumor is usually between 
the second and fourth ribs, anteriorly, but may be seen lower on the 
side or even well below in the back. Pulsation is not, as some consider 
it, a sign of necrosis of the pleura; it has been attributed, though with- 
out satisfactory reason, to such causes as coincident pneumothorax 
(Fereol), atelectasis of the lung (Comby), or adhesions and paresis of 
the intercostal muscles (Traube, Keppler). The most apparent con- 
ditions for pulsation in an empyema, are considerable cardiac energy, 
massive exudation and paresis of the intercostal muscles. Empyema 
pulsans may be confused with aneurysm, which latter is much slower 
in its evolution, is much oftener located above and to the right, and has 
its own signs, murmur, and thrill; it may be confused with pulsating 
abscess, gangrene or tumor of the lung and pulsating pneumonia. The 
pulsation ceases after aspiration. Aneurysm may co-exist with pleurisy. 
Expansile pulsation of the chest wall has been observed twice without 
exudation, aneurysm or any organic change (Lafleur and Edwards). 

Empyema may rupture externally, empyema necessitatis. Rupture 
is usually along the sternum or lower ribs. Gravitating abscesses may 
result, as pulsating tumors in the groin and loin, which may be con- 
fused with aneurysm or spinal caries. Rupture into the lung may 
cause suffocation during sleep; according to Netter, 25 per cent, of 
post-pneumonic empyemas rupture into the bronchi. Fistulse, hectic 
fever and amyloidosis are frequent sequelse. Hippocrates knew of the 
"mouth full" expectoration and also the fact, later described by 
Traube, that pus may penetrate the lung like a sponge without per- 
foration or pneumothorax. Unverricht thinks, however, that perfora- 
tion into the lung without pneumothorax is probably caused by a small 
opening which allows the escape of fluid into the lung but does not allow 



PLEURISY 553 

the escape of air into the pleura, because of the higher tension in the 
exudate. Hallin (1905) found 114 cases of bilateral empyema recorded 
in the literature; 67 per cent, occurred in males and 90 per cent, in 
young persons under fifteen years old; the mortality was 30 per cent. 

4. Putrid pleurisy is usually associated with gangrene of the lung, 
pneumothorax, oesophageal carcinoma, appendicular abscess and 
kindred lesions. The fluid is extremely foetid; fat, leucin, tyrosin, 
cholestearin and sometimes haematoidin crystals are found; the colon 
bacillus and other gasogenic bacteria are frequently present. 

5. Hemorrhagic pleurisy is usually serofibrinous, and the exudate 
is tinged with blood. Five to six thousand red cells per c.mm. are neces- 
sary to produce a reddish tinge. Its character is seldom suspected be- 
fore puncture, (a) Most cases are tuberculous. Dieulafoy speaks of these 
cases as having " haemoptysis into their pleurae. " After puncture, more 
fluid is frequently formed, but recovery is possible. (6) Some cases are 
cancerous; Moutard-Martin has found hemorrhagic pleurisy in but 12 
per cent, of pulmonopleural cancer; pain, dyspnoea, luxation and 
rapid pulse are frequent symptoms; the fluid is dark red, contains 
little fibrin, and is usually formed rapidly; a case of Desnos was 
punctured 30 times in six months, (c) Some cases occur in liver cirrho- 
sis (of which Laennec published the first case in 1826), in nephritis, and 
in hemorrhagic fevers or exanthemata; profuse hemorrhage into the 
pleura was called pleural haematoma by Wintrich and pachypleuritis 
hemorrhagica by Chouppe from its resemblance to hemorrhagic pachy- 
meningitis. 

6. Chyliform pleurisy occurs chiefly in pleural neoplasms or in 
tuberculosis; the fluid is milky, contains fatty droplets, fatty cells and 
albuminous detritus in suspension; cholestearin and lecithin may be 
found (v. i. Chylothorax). The exudate is sometimes colloid. 

In multilocular exudation, in which one pocket contains pus, another 
serum, a third hemorrhagic fluid, etc., Galliard speaks of polymorphous 
pleurisy. 

II. Location of the Exudate. — 1. Pleuritis diaphragmatica pro- 
duces much subjective disturbance. Radiating pain is often experi- 
enced, which may resemble that of angina pectoris (Andral). Pain 
and tenderness in the epigastrium and between the tenth rib and the 
xiphoid, is pathognomonic, according to Gueaneau de Mussy. 

Schmidt's respiratory abdominal reflex, an inspiratory spasm of the 
upper part of the rectus muscle, is rather indicative of phrenic involve- 
ment. Dysphagia from inflammation of the foramen cesophageum 
may result. If left-sided, vomiting and singultus may be noted, and 
if right-sided, icterus is not uncommon. Cough may occur spontan- 
eously or on pressure. Pressure in the lower interspaces near the spine 
elicits tenderness; tenderness over the cervical portion of the phrenic 
nerve may be noted, together with reflected pain along the mammillary 
branches of the cervical nerves to the shoulder. Dyspnoea is usually 
great, the temperature is generally normal, the lower chest moves but 
little, the respiratory murmur is very weak, and friction may be heard 



554 DISEASES OF THE RESPIRATORY TRACT 

over the liver or in the "half -moon" space of Traube. If there is no 
exudate, the diaphragm may remain high. Fluid may accumulate 
between the diaphragm and lung without reaching the chest wall, and 
therefore without causing dulness. Fibrinous is more common than 
serous effusion. 

2. Interlobar pleurisy is difficult to diagnosticate, as there is little 
surface dulness. The amount of exudate may vary from a few c. c. up 
to 400. It occurs most frequently after lobar pneumonia or in tubercu- 
losis. Previous pleurisy may favor its development by marked adhe- 
sions obliterating the general pleural space. As Laennec noted, it is 
almost always suppurative. Its early diagnosis is uncertain, for the 
fever, rales, cough and dyspnoea are suggestive of a lesion of the lung; 
later a zonular dulness is found conforming to an interlobar fissure; 
the dulness is bounded above and below by a normal or somewhat 
over-resonant note. The heart may be pushed to the right, when there 
is left-sided localization, but the liver is not luxated in right-sided 
localization. The symptoms may resemble those of lung abscess from 
which during life differentiation is sometimes impossible. Interlobar 
pleuritis may be shown clearly by the x-rays. Large effusions may 
break internally, and pus is then suddenly detected in the sputum. 
Haemoptysis may occur. Puncture is attended with some danger, as 
the lung may be infected by the needle, during its withdrawal. 
Spontaneous recovery is infrequent. The outlines of the lobes are 
shown in Figs. 33, 34 and 35. 

3. Mediastinal pleurisy, described by Laennec and Andral, is most 
often tuberculous or pneumococcic, and more frequently purulent than 
serous. The symptoms of lung compression are less distinctive than 
are those of compression of the mediastinal tissues. There may be 
wheezing, dyspnoea, dysphagia, fever, intrathoracic oppression or 
pain, a pertussis-like cough, enlarged thoracic veins from azygos com- 
pression, deviation of the larynx or trachea, and dulness between the 
scapula and spine; the x-rays picture may be suggestive. The sudden 
onset and febrile course differentiate it from aneurysm, tumor, and 
adenopathies. The outlook is unfavorable, without operation. 

4. Peri- (para-) pleuritis (Wunderlich, Bartels, Billroth) is an 
inflammation outside of the parietal pleura, and is usually purulent. 
Some cases follow glanders, but most of them are due to actinomycosis. 
Fistulse and the evacuation of the characteristic sulphur granules are 
common. The symptoms are more local and irregular than those 
of pleurisy; fluctuation is more frequent; heart dislocation and lung 
compression are rare; the respiratory excursion is free, and on heavy 
percussion lung resonance may be elicited beneath the dulness. 
Metastatic inflammation, perforation and burrowing are common. 

III. Pleurisy in Children. — In children pleurisy is attended by more 
general symptoms, higher temperature, higher pulse and more rapid 
respiration rate. Bronchial breathing is more frequent, there is less 
dulness, less luxation, and less friction. It often follows pneumonia, 
where, in the majority of cases, the empyema is more benign. Tuber- 



PLEURISY 



555 



culosis is less frequently causative in children than in adults. Accord- 
ing to Lemoine, metapneumonic pleurisy is distinguished from the 
parapneumonic type, by its slower course. 



Fig. 33. 




Ftg. 34. 



Fig. 35. 





Cuts from Dieulafoy, showing: Fig. 33, the posterior surface of the lungs and their interlobar 
fissures; Fig. 34, the lateral aspect of the left lung; and Fig. 35, that of the right lung. 

Course. — The course of uncomplicated pleurisy averages three to 
six weeks; acute cases last two, sub-acute three to eight, and chronic 
eight or more weeks. No general rule can be laid down, and the onset, 
whether mild or stormy, is no index of the issue. No cycle is seen in any 
form of pleurisy. Pleuritis acutissima, with high fever, typhoid sym- 
toms and early death is fortunately rare. Friction along the lowest 
limits of the pleura and in front rarely attends great effusions and 
therefore (after the exclusion of tuberculosis, carcinoma or pyaemia) 



556 DISEASES OF THE RESPIRATORY TRACT 

the prognosis is relatively good. In the average case dry pleurisy pre- 
cedes and succeeds exudation. Recurrence and exacerbations render 
the prognosis unfavorable. Death frequently follows from exhaustion 
and gradual cardiac failure. Partial absorption with persistence of 
temperature or with dyspnoea is indicative of tuberculous pleurisy. 
Rheumatic pleurisies heal more readily than tuberculous. The author 
has seen recovery of secondary carcinomatous pleurisy. 

Issue. — 1. Resorption. — Resorption may occur and even purulent 
(pneumococcic) pleurisy may, in exceptional cases, be absorbed in part 
without operation or rupture, leaving inspissated caseous accumu- 
lations. Serous pleurisies may be absorbed after three to six months, 
during which time persistent friction is common over the lower part of 
the chest. 

2. Adhesions. — The thickness of pleural adhesions is more important 
than their extent. Universal obliteration of the pleura by thin adhesions 
is often of no consequence. Retraction of the lung, compensatory 
emphysema, pain, thoracic oppression, obliteration of the comple- 
mentary pleural space, dulness, decreased vocal fremitus and breathing, 
failure of Litten's phenomenon, decreased respiratory excursion and 
stagnation of bronchial secretion may occur when the adhesions are 
thick. If there is exudate around the heart, the apex beat may in- 
crease during the inspiration; this also occurs in bronchial catarrh 
(Eichhorst). Failure of the right heart and stasis may ensue, though 
most extensive adhesions sometimes exist without cardiac embarrass- 
ment. Peritonitis, mediastinitis, induration and obliterative peri- 
carditis may complicate the case. In some instances the pleura 
calcifies or ossifies, leaving a deposit measuring three cm. or more in 
thickness. 

3. Sudden Death. — Fatal syncope may result after exertion, after 
coughing or after the efforts of urination or defecation. Sudden death 
may occur from paralysis of the left ventricle, from cardiac thrombosis, 
pulmonary oedema, bending of the aorta, compression of the cava at 
the diaphragm, and rarely from pulmonary embolism caused by venous 
thrombosis. Rupture of fluid into the lung or bronchi, which may 
drown the patient during sleep, and death from hemorrhage into the 
effusion, from pneumothorax, or from brain embolism are even rarer. 

4. Retractio Thoracis. — Retraction is characterized by increased 
resistance, decreased fremitus, decreased circumference of the affected 
side and often by bronchiectasis. The percussion note is dull and the 
breathing is usually decreased, but sometimes is bronchial. The causa- 
tive factors are atmospheric pressure, contraction of the pleural scars, 
extension of the inflammation into the lungs, and pleurogenous (inter- 
stitial) pneumonia, which is also known as pleuritis deformans, and 
which sometimes divides the lung up into lobes or islets. Retraction 
is generally a slow process but the writer has seen marked deformity 
develop in three weeks. 

5. Changes in Other Organs. — When retraction occurs, other organs 
may be dislocated. The liver may be higher when the right side is 



PLEURISY 557 

involved, and in left-sided retraction the lung may shrink away from 
the heart, the spleen and the heart may lie higher and Traube's space 
may be increased. Organs displaced by exudate may in rare cases 
remain luxated after the exudate is absorbed. Pleural callosities may 
produce recurrent laryngeal paralysis which may also follow the pres- 
sure of a fluid exudate or enlargement of the glands. Other compli- 
cations are acute and chronic infiltration in the lung; inflammation and 
degeneration in the chest muscles; extension to other serous surfaces; 
septicopyemia ; stasis in the liver, stomach, extremities, etc.; hem- 
orrhages into the skin; chronic nephritis; amyloid degeneration and 
pulmonary, glandular, genito-urinary or miliary tuberculosis. Scag- 
liari, quoted by Eichhorst, reports forty-seven cases of paralysis of the 
arm, probably due to brachial neuritis. 

Diagnosis. — The physical findings only are final; symptoms are 
most unreliable. Diagnosis of the malady is the first step, and the 
second is the determination of its cause. 

Differentiation. — 1. The diagnosis of pleuritis sicca is established 
only by feeling or hearing the friction rub. (a) It must be distinguished 
from rales. The crepitant rale is largely inspiratory, and is heard as a 
number of small rales at the end of inspiration. Bronchitic rales or 
rhonchi are continuous. Coughing and deep inspiration alter or re- 
move rales but the pleural rub is increased by pressure and deep in- 
spiration, and is less extensive. It may disappear after a number of 
deep inspirations, because this makes the two surfaces temporarily 
smooth, (b) It must be differentiated from sacculated breathing and 
from the physiological, bilateral cracking in the chest muscles on deep 
breathing, (c) Distinction is necessary from intercostal neuralgia, 
which is intermittent, occurs in typical attacks and is limited to the 
interspaces ; Valleix's points are usually but not always present ; they 
exist at the angle of the ribs, in the middle of the axilla and anteriorly, 
and correspond to the points of exit of the posterior, lateral and an- 
terior perforating branches of the intercostal nerves. Intercostal 
neuralgia is increased less on deep breathing than is pleuritic pain. 
(d) Pleuritis sicca must be differentiated from caries of the ribs, in which 
pain is localized directly over one rib and not between the ribs, (e) 
It must be distinguished from rheumatism of the thoracic muscles. 
This may be very difficult, for both affections may induce pain on 
breathing, tenderness and disturbed breathing; there may be a history 
of cold or exposure, or of repeated attacks. There is usually no fever 
or cough. Faradization decreases the pain, and movement increases 
it more than is the case in pleurisy. (/) The rub in pericarditis (q. v.) 
is more distinctly cardiac, and depends upon the cardiac movements. 
In pleurisy along the border of the heart, on holding the breath the 
pleuritic rub is heard near or over the heart, and decreases after 
five or six heart beats. On very deep inspiration the pleural rub 
ceases and the pericardial rub is increased. Differentiation is most 
difficult when there is pleurisy over the lingual lobe and left border 
of the heart, though pericarditis most commonly produces a rub at 



558 DISEASES OF THE RESPIRATORY TRACT 

the base of the heart, especially over the conus pulmonalis arter- 
iosus. 

2. Pleuritis humida (pleuritis effusiva) must be distinguished (a) 
from infiltration of the lung substance (see table in Diagnosis 
of Pneumonia). The fremitus is decreased in pleurisy, increased 
in consolidation; if a bronchial plug decreases the fremitus in 
consolidation, it can usually be dislodged by coughing. In con- 
solidation the dulness often corresponds to one lobe; the pleuritic 
dulness increases downward, though the upper border of dulness 
in pneumonia is also sometimes irregular. Only when pneumonia 
involves an entire lung is there any luxation of the heart, or in- 
volvement (in left-sided pneumonia) of Traube's space. In con- 
solidation there is a close topographical parallelism between the 
intensity of the bronchial breathing and the degree of dulness. When 
there is very slight bronchial breathing, pleurisy is probably not present 
although it may exist in some cases. The sputum, the length of the 
clinical course, dislocation of the heart, liver, and spleen, the infre- 
quency of chills, the ectasia shown by the cyrtometer and the solution 
by lysis, are indicative of pleurisy. iEgophony occurs more frequently 
in pleurisy along the upper border of the fluid, but is usually transitory. 
Exploratory puncture is the final test and also determines the nature of 
the fluid. The presence of blood, carcinoma cells, streptococci, pneu- 
mococci, tubercle bacilli, etc., are of diagnostic value. (6) It must be 
differentiated from tumors of the lung, which produce cachexia, nar- 
rowing of the chest behind on one side, and the characteristic exudate; 
this is often brown (Fraenkel) and sometimes chyliform, and contains 
fat globules (Quincke) and degenerated large cells which may show 
mitoses ; the glands above the clavicle may be enlarged as well as those 
in the mediastinum, which produce recurrent laryngeal paralysis. 
Tumor particles are rarely obtained by puncture or in the sputum, and 
are only found in carcinoma, for sarcoma rarely ulcerates. When 
tumors of the lung are suspected, a trocar rather than a needle should 
be used. There is more resistance to puncture in tumor than in 
pleuritis. Unverricht observed the development of carcinoma at the 
seat of puncture. In tumors there is less displacement, less invasion of 
Traube's space and less widening of the chest than in pleurisy, and the 
breathing is often bronchial, the flatness is intense and the fremitus is 
increased, (c) Hydrothorax (q.v.), which is usually described as 
bilateral, may nevertheless be unilateral, especially in disease of the 
liver, kidneys and heart, where right-sided hydrothorax is observed. 
Unilateral hydrothorax is sometimes' caused by obliteration of the 
other pleural cavity by adhesions. The fluid readily shifts its level 
on change of posture, which does not occur in pleurisy. Salicylic acid, 
iodine and potassium iodide are said to pass readily into transudates, 
and but slowly and in small -amounts into exudates (Rosenbach and 
Pohl), though this claim has been disproven by Weintraub, Leuch and 
Feldmann. (The iodine is detected by adding nitric acid and shaking 
with chloroform, which becomes red colored.) In hydrothorax, the 



PLEURISY 559 

specific gravity is below 1,014, the albumin is less than 3 per cent, and 
the sediment shows few white cells and some endothelial cells, which 
are not pathognomonic of hydrothorax, as has been claimed. Bac- 
teriological tests are negative, (d) The presence of hemothorax is 
determined only by puncture. 

3. Circumscribed 'pleurisy in some instances requires differentiation. 
(a) It differs from pericarditis in that it shows a more irregular outline, 
the apex beat is not altered and there is no cardiac insufficiency or 
pericarditic friction. (6) It may be distinguished from lung cavities, 
which show dulness when full of secretion and resonance when the 
secretion is voided; the fluid obtained by puncture (which is made 
under a wrong diagnosis) has a higher specific gravity and a larger per- 
centage of fat than that of pleurisy, (c) Differentiation from splenic 
tumors is determined by respiratory excursion and palpation of the 
lower edge of the spleen, (d) Liver enlargements rarely occur solely 
upward, save in echinococcus and in abscess of the convexity; these 
are prone to occur anteriorly, and pleurisy is more frequently detected 
posteriorly. In tumors of the liver there is usually respiratory excursion 
which is absent in pleurisy. In rare instances of very large right-sided 
pleurisy there is a furrow between the costal arch and the liver down- 
ward (Stokes), (e) It should be differentiated from subphrenic abscess 
(v. Localized Peritonitis), which may be intraperitoneal (as from 
liver abscess) or extraperitoneal (e. g., perinephritic). The liver stands 
higher in the chest because of the paretic diaphragm. There may be a 
history or physical signs of previous disease of an abdominal organ. 
The needle, when thrust toward the abscess, reaches the pus only when 
thrust deep in the lower interspaces. The pus has frequently a 
faecal odor. The manometer shows increased pressure during in- 
spiration and decreased pressure during expiration, the converse of the 
findings in pleural effusion. (/) It must be distinguished from abscess 
of the liver. Pleurisy, either serous or suppurative, may complicate 
abscess of the liver. Differentiation is easy when abscess of the con- 
vexity is located forward; when it is situated posteriorly, aspiration 
alone will distinguish it; the pus shows liver cells, amoebae, choles- 
tearin, and bile. 

Prognosis. — The immediate mortality is about 5 per cent., though a 
prognosis cannot be made in the first week or two. (a) The etiology 
is an important factor. (6) The nature of the fluid is of prognostic 
import. Fibrinous pleurisy (except when it occurs at the apex of the 
lung) is the most favorable type. Prince Ludwig Ferdinand considers 
the prognosis in the effusive forms as follows: (i) most favorable in 
metapneumonic serous or purulent pleurisy; (ii) next most favorable 
in serous pleurisy due to the staphylococcus, (iii) less favorable in 
staphylococcus empyema, (iv) least favorable in tuberculous, foetid 
or putrid forms. The prognosis is usually poor in hemorrhagic, chyli- 
form, peracute and bilateral (generally hemorrhagic or purulent) 
effusions. It is more favorable in effusions which are relatively rich in 
solid constituents (Mehu and Bernheim); effusions containing little 



560 DISEASES OF THE RESPIRATORY TRACT 

solids are apt to recur. When the freezing point of the exudate is found 
by cryoscopy to be below that of the blood, spontaneous absorption is 
unlikely to occur (Rothschild), From a study of 116 cases of effusive 
pleurisy, Courmont (1906) concludes that the mortality is 25 per cent, 
in effusions which have an agglutinating power for the tubercle bacil- 
lus, and 75 per cent, in effusions which have not. Since the time of 
Hippocrates, the belief has prevailed that right-sided are less favorable 
than left-sided effusions, (c) The persistence of temperature and 
sweats, anaemia, recurrences, and external rupture are unfavorable. 
(d) Sudden death is more frequent than it is usually believed to be. 
The author saw three cases in one year. 

Opinions vary as to the ultimate prognosis. Eighty-seven per cent, 
of cases become tuberculous in one to two years (Fiedler); 33 per 
cent die in five years (Bars); 66 per cent, are curable (Osier); 15 per 
cent, die of tuberculosis, 90 per cent, are in good health after two to 
five years and 80 per cent, are healthy after five years (Cabot). 

Treatment. — Etiological treatment can be applied only to the rheu- 
matic and syphilitic forms. 

Treatment of fibrinous pleurisy, which remains fibrinous, or in the 
fibrinous or first stage of exudative pleurisy. Pain is the main indi- 
cation; morphine may be given in severe cases, especially when 
coughing is severe; the ice-bag, poultices, blisters, cups and hot fomen- 
tations give little relief when the pain is acute ; blisters may eventually 
cause as much pain and discomfort as the disease itself; the pleura 
should be splinted by three or four strips of adhesive plaster two inches 
wide, overlapping the median line before and behind by about three 
inches, and running around the chest horizontally and obliquely; these 
should be applied with considerable pressure during expiration that the 
lung in its lower part and the pleural surfaces may be well immobilized ; 
zinc oxide adhesive plaster is least irritating to the skin. Personal 
experience with the early use of salicylates, which are advocated by 
Aufrecht and Fiedler, has not been satisfactory. The patient should 
be kept in bed. The use of leeches sometimes relieves the pleural con- 
gestion. 

In serous pleurisy, the patient should be kept in bed, and the cough 
and fever should be treated expectantly. Laxatives are given solely to 
obviate straining at stool, which may induce cardiac weakness; pur- 
gatives do not reduce the amount of the effusion. If at the end of the 
second week the effusion shows no sign of being absorbed, various 
measures are indicated; Schroth's treatment consists in limiting the 
amount of fluid ingested to about one quart (1000 c.c.) daily, but it has 
few adherents, as the method gives no results and exudation is an 
active, not a passive process; tincture of iodine may be applied, but is 
seldom beneficial, and when old is distinctly a local irritant; potassium 
iodide, digitalis, drastics to produce copious evacuations, pilocarpine 
(combined with cognac to support the heart), cotton jackets and sweats 
are often given. Of late a salt-free diet (dechlorination) is advised, as 
in nephritis (q. v.). The author cannot agree that any of these meas- 



PLEURISY 561 

ures are helpful and believes pilocarpine is always dangerous. Trans- 
udates may be removed in this way but not exudates. 

Aspiration. — Trousseau's indications were (a) the vital indication 
(when life is threatened, because of large exudates) ; (b) moderate 
effusions with slow resorption, and (c) persistent or residual exudates. 
The author believes that early puncture (thoracocentesis) and aspira- 
tion are indicated in every case, where two quarts or more (2,000 or 
2,500 c.c.) of fluid are effused, whether the temperature is still high or 
not, and whether pressure symptoms or dyspnoea are present or not. 
This amount of effusion causes dislocation of the heart, liver or spleen, 
compression of the lung, or ectasia, as shown by the cyrtometer; intra- 
thoracic pressure may cause sudden death, sometimes without any 
warning symptoms of cardiac insufficiency. Early puncture does not 
irritate the pleura nor favor recurrence or suppuration. Early and 
repeated puncture obviates compression of the lung and atelectasis as 
well as compression and torsion of the large arteries. Aspiration was 
first advocated by Wyman and Bowditch of Boston more than 50 
years ago. 

Method of Aspiration. — After the usual surgical antisepsis, a small 
trocar or large aspirating needle is introduced, which has an elbow 
connecting with a rubber tube, to siphon the fluid to a vessel below, or 
connecting with a bottle which can be exhausted by a pump. There is 
no absolute rule as to the site of puncture. This must be governed 
solely by the physical signs; for instance, adhesions which hold the 
lung to the surface vitiate any set law; fluid is usually obtained most 
advantageously between the scapular and post-axillary lines and low 
down in the chest. The trocar should be introduced suddenly, to 
avoid bending of the spine which narrows the interspaces; it should be 
introduced perpendicularly to the chest wall and not obliquely, in order 
to avoid injuring the intercostal artery, as a result of which the author 
once saw fatal hematoma and hemothorax. Whisky and hypo- 
dermics should be at hand, because of the possibility of syncope. The 
use of the pump is necessary in but 10 per cent, of cases, for the fluid 
can usually be siphoned readily; a tube is attached to the needle or 
trocar, filled with boric acid solution, clamped with an artery 
forceps and undamped, when it is placed in a basin containing the 
same solution and at a somewhat lower level than the seat of 
puncture. The fluid, if pumped, should be withdrawn gradually; 
caution is necessary lest air be pumped the wrong way, i. e., into the 
pleura. The amount removed need not be great, as moderate relief of 
intrapleural tension often promotes absorption. The amount to be 
withdrawn is estimated somewhat arbitrarily at one quart (1,000 c. c, 
Naunyn and Dieulafoy), or three pints (1,500 or 1,600 c.c, Fraenkel and 
Bowditch). Complete or nearly complete evacuation may cause the 
accidents enumerated below and is thought by Litten to induce miliary 
tuberculosis. Aspiration should be discontinued when the exudate 
becomes bloody (from lung injury), when friction develops, when pain is 
felt or when coughing (from congestion of the relaxed lung) begins. 

36 



562 DISEASES OF THE RESPIRATORY TRACT 

Repetition of puncture depends on the results attained; it maybe repeated 
every two or three days. Favorable results are slowing and strengthen- 
ing of the pulse, relief of oppression, increased diuresis, and improved 
appetite; but relief of pressure on the lung and absorption of the 
exudate are of the greatest importance. Unfavorable results are (a) 
syncope due to cerebral anaemia which in turn results from restoration 
of circulation in the collapsed lung, which contained little blood before 
it was relieved by the puncture, a relatively uncommon occurrence; 
(b) pulmonary oedema, the albuminous expectoration described by 
Terillon, Besnier, Johnson, Duffin, and Scriba, which is due to the 
sudden withdrawal of too much fluid (two to five liters) at one 
tapping; it should take a half -hour to evacuate one and a half quarts 
or 1,500 c. c. (Fraentzel) ; oedema pulmonum is treated most efficaciously 
by hypodermics of morphine, gr. \ and some clinicians advise giving 
it before aspiration; (c) sudden death from pulmonary embolism or 
cerebral embolism; the latter results from discharge of clots from 
vessels in the relaxing lung, and causes the so-called pleuritic hemi- 
plegia; some of these cases are hysterical hemiplegia; (d) injury to the 
heart, liver or spleen; (e) pneumothorax or subcutaneous emphysema 
may occur though the author has never seen either of them. (/) The 
author once witnessed an extensive haemothorax and subcutaneous 
hsematoma in a pleural puncture, in which the trocar was impatiently 
thrust in and out during an unsuccessful thoracocentesis, (g) Fi- 
brinous bronchitis has apparently followed paracentesis. When repeated 
punctures fail to produce the desired results, the advisability of 
operation (as in empyema) should be considered. 

Empyema in all cases necessitates operation (practised by Euryphon 
and after him by Hippocrates) . Some cases may recover spontaneously, 
but this cannot be depended upon. A day before operation, aspiration 
is indicated when the fluid is under high tension, thereby relieving the 
heart. Some surgeons advocate treating tuberculous empyema without 
operation, as Volkmann treated other cold abscesses; Kronlein ob- 
served, after operation on these cases, recovery in 36 per cent., improve- 
ment in 28 per cent, and death in 36 per cent. Results depend on the 
etiology and bacteriology. Though the mortality in Velpeau's cases 
was 100 per cent, and that of Dupuytren was 92 per cent., at the 
present time it is but little over 1 per cent. 

Putrid pleurisy should be treated like empyema. 

Hemorrhagic effusions may necessitate injections of gelatin sub- 
cutaneously; the amount aspirated should not exceed one pint (500 
c. c.) and aspiration should be repeated as seldom as possible. 

After-treatment is directed toward prevention of thoracic retraction, 
to which end gymnastics and deep breathing are essential. A patient 
having suffered from a " primary" effusive pleurisy should be treated 
as one with latent tuberculosis. 



PNEUMOTHORAX 563 



(B). PNEUMOTHORAX. 

Definition. — Pneumothorax is an accumulation of- gas or air in 
the pleural sac. It was named by Itard of Paris (1803) and was 
described fully by Laennec (who made the first diagnosis) and Skoda. 
As it excites pleurisy in more than half the cases, the following varie- 
ties are distinguished: pyo-, sero-, and hamopneumothorax. There is 
no name for putrid pneumothorax. 

Etiology.-— Diseases of the lungs and pleura cause about 95 per 
cent, of all cases. In Biach's collection of 918 cases in Vienna, pul- 
monary tuberculosis was causal in 77 per cent., gangrene in 7 per cent., 
empyema 5 per cent., trauma 3 per cent., bronchiectasis and abscess 
each 1 per cent., the etiology was unknown in 2 per cent, and the 
remaining 4 per cent, was due to emphysema, infarct, thoracocentesis, 
echinococcus and contiguous disease perforating into the pleura, as 
gastric or oesophageal ulceration, or caries of the sternum. By other 
writers (a) tuberculosis is thought to cause 80 per cent, or even over 
90 per cent.; Mosheim found that 84 per cent, were tuberculous, of 
which 6 per cent, were curable; acute forms are more important 
than chronic tuberculosis in which there are protecting pleural adhe- 
sions; pneumothorax develops in two (Drasche) to six (Eichhorst) 
per cent, of tuberculous cases, (b) Ulcerative lesions of the lung, as 
gangrene, abscess, bronchiectasis, tumors, parasites and infective 
infarcts may naturally erode the pleura and admit air. (c) Trauma, 
rupturing of the lung directly or by contra-coup, thoracocentesis or 
stab wounds, occur far less frequently than one would expect, (d) 
Empyema; it may rupture into the lung without allowing ingress of 
air from the opposite direction, (e) Rupture of a healthy lung after 
coughing or muscular straining is a possible though very exceptional 
cause. Pneumothorax has followed violent coughing in pertussis. 

Perforative lesions in the mediastinum, oesophagus, peritoneum, 
stomach or colon and subphrenic abscess are uncommon (v. s.) causes. 

Pneumothorax may occur spontaneously. It is always possible, 
however, that a point of rupture in the lung is overlooked or has 
healed over, and the fact remains that air enters the pleura chiefly 
from the lung or from a gas-containing organ. The view held by 
Oppolzer, Biermer and others that putrefaction may occasionally 
develop primarily (without rupture) has received confirmation by 
discovery of the Bacillus aerogenes capsulatus and other gasogenic 
organisms (Lewy, Welch and Fraenkel). 

Pneumothorax occurs largely in adults and four to seven times as 
frequently in males as in females. Eichhorst and Drasche find it 
more often on the right side, Powell on the left, and West on either 
side with equal frequency. 

Pathology. — When the chest is opened, air or gas escapes with a 
force sufficient to blow out a candle. The volume of air may exceed 
2,000 c.c, and its tension, which was studied first by Wintrich and 



564 DISEASES OF THE RESPIRATORY TRACT 

then by Weil, compresses the lung and causes it to collapse, dislocates 
the heart and mediastinum and depresses the diaphragm and sub- 
phrenic organs. The gas may be odorless or foetid. The pathological 
and clinical findings vary (a) as the gas is encapsulated or occupies 
the entire pleural cavity; (b) as the air is aseptic (producing a pure 
pneumothorax, or one with slight exudation) or is infected by tubercle 
bacilli, pyogenic organisms, colon bacillus, or monads according to 
the primal disease; microorganisms excite serous, purulent or putrid 
pleurisy; (c) as the air-containing cavity is "closed," "open" (into 
a bronchus, or sometimes also open externally) or possesses a valve, 
thus allowing passage of air in one but not in the opposite direction. 
These points will be considered below. 

Symptoms. — The onset is usually sudden, for rupture may occur 
spontaneously or may follow coughing or muscular exertion; it is 
characterized by sudden pain in the side, cyanosis, dyspnaa and col- 
lapse, which are due to reflex action on the vagus ; there may be sudden 
evacuation of pus from the breaking into the lung of an empyema; 
an urticaria (Gerhardt, Senator) occasionally develops, just as a toxic 
rash may follow echinococcus rupture; decreased diuresis, albumin- 
uria, stasis and subcutaneous emphysema are sometimes observed. 
The onset may be insidious for pneumothorax sometimes constitutes 
an unexpected post mortem finding. In other instances the previous 
history or the course may justify a presumptive diagnosis, as in a 
case clearly tuberculous; and in still other cases, a latent lung lesion 
(a small caseous focus) may burst and thus produce its first symptom. 

Physical Findings. — 1. Inspection.— (a) The affected side is dis- 
tended 2 to 4 inches (5 to 10 cm.) and immobile, and contrasts sharply 
with the widely-moving sound lung, (b) The interspaces are obliter- 
ated, (c) The heart and liver or spleen are dislocated, (d) There are 
dyspn&a and cyanosis, (e) The attitude is characteristic; the patient 
most often lies on the affected side to afford ample play to the sound 
lung; sometimes there is orthopncea and if the point of rupture opens 
into the lung or bronchus, a peculiar decubitus may be assumed, in 
order to drain the pleura. (/) The x-rays show that the lung is 
flattened near the spine, that the diaphragm is depressed and motion- 
less, and they also show the shadow of the effusion. 

2. Palpation. — (a) Vocal fremitus is absent, unless adhesions hold 
part of the lung to the chest wall, (b) The chest wall feels resistant 
and (c) sometimes splashing, fluctuation or a "pillow sensation" is 
noted, (d) The dislocated apex beat and the edge of the liver or spleen 
are felt. 

3. Percussion. — Somewhat different results are obtained by per- 
cussion according to the tension of the gas and of the chest walls, 
(a) In open pneumothorax the note is full and tympanitic, and even 
metallic when percussion is made on a solid object, as a coin; this 
metallic reverberation was called bruit d'arain by Trousseau; cracked- 
pot resonance and Wintrich's change of note may be elicited when 
the mouth is opened, (b) In closed pneumothorax the note is full and 



PNEUMOTHORAX 



565 



loud; it is tympanitic when there is moderate pressure and the inter- 
costal muscles are relaxed; again the note may be dull (Skoda) if the 
tension is great, or if the chest muscles are spasmodically contracted, 
as in sudden pneumothorax (vagus reflex action), (c) Flatness over 
the lower thorax usually results from pleural effusion. (This dulness 
may occur without coincident pleurisy, and, conversely, the author 
has seen tympany prevail over the entire side, even when there was 
much coincident pleural effusion.) (d) On change of posture, a 
changing level of the fluid is readily elicited, the gas being found above 
and the fluid below, for the gas acts in this respect as a spirit-level; 

Fig. 36. 





i II- 

I. Left-sided effusive pleurisy, showing relative heart dulness (A), effusion (B), liver flatness 
(C), and fluid impinging on Traube's half-moon space, of which but a small part remains 
resonant (D). 

In larger effusions reaching, e. g., up to the dotted black line, the relative heart dulness may be 
pushed over to the dotted line (over C). 

II. Left-sided pneumothorax marked by tympany (T. T.). pushing over the mediastinum and 
also the heart to the right, and pushing down the left lobe of the liver and the spleen. 

this change is far more important than in simple pleurisy, as there are 
no adhesions, (e) The pitch over the gas-distended part changes 
with change of posture (Biermer's change of note). It becomes deeper 
as the patient sits up, because the vertical dimension of the chest is 
thus increased by the pushing down of the diaphragm. (/) The heart 
dulness is replaced by resonance in left-sided pneumothorax, and is 
found to th'e right of the sternum; in right-sided pneumothorax it is 
pushed to the left axilla, (g) The dulness of the liver or spleen is 
pushed well downward. 

4. Auscultation. — (a) The breath sounds are usually absent in the 
closed variety of pneumothorax, and this, with ectasia and hyperreso- 
nance, is most characteristic. In the open and sometimes in the closed 
form, the breath sounds are bronchial, amphoric or metallic, the 
voice sounds, especially under the clavicle, are metallic (metallic 
bronchophony), and coincident rales in the bronchi are also metallic. 



566 DISEASES OF THE RESPIRATORY TRACT 

(b) Air passing through the point of rupture may produce curious 
snapping or whistling sounds; the point of rupture is oftenest at the 
lower anterior part of an upper lobe, i. e., between the second and 
fourth interspaces, and between the mammary and axillary lines, (c) 
The gutta cadens (the metallic " falling drop") may be due to dripping 
of fluid from fibrin shreds as the patient's posture is changed, or to 
rales. (d) The Hippocratic splashing (succussio Hippocratis) is 
elicited by placing the ear to the chest and sharply shaking the patient; 
it is sometimes heard at some distance from the patient, and in three 
cases patients have spontaneously called the author's attention to a 
"splashing in the chest"; it is oftenest heard in the side or in the 
interscapular area, (e) The heart tones may be metallic, and the heart's 
action may even cause splashing sounds. 

Diagnosis. — The ectasia, the resonant note, suppressed or amphoric 
breathing, cardiac and other luxations and succussion are most char- 
acteristic. 

Type. — Contrary to the usual statements, Weil recently proved that 
dislocation occurs in all types, though it varies in degree, (a) In the 
open form Wintrich's change of note on opening the mouth, metallic 
sounds, the fistula murmur, periodic expectoration of large amounts 
of pus, moderate cardiac and other dislocations and no manometric 
increase of the tension in the pleura are distinctive. Colored fluid 
(methyl blue), if injected into the pleura, is coughed up. (b) The 
closed type is distinguished by increased manometric tension, absence 
of breath sounds, marked ectasia, change of note on sitting but not on 
opening the mouth, and marked luxations, (c) In the valvular form 
air may enter the pleural cavity but cannot escape back and therefore 
pus cannot be voided. Some of the auscultatory findings of the open 
type are noted. The manometer shows increased pressure. The 
fistula may become permanently closed by organic change (organic 
type), so that aspiration of the air is not followed by further accumu- 
lation; or the fistula may be only mechanically closed, and air may 
accumulate again after its aspiration. 

Differentiation. — (a) Cavities may be simulated by circumscribed 
pneumothorax, but in cavities the interspaces are sunken, the fremitus 
is increased (when they are empty), luxation is absent and the Hippo- 
cratic succussion and coin sound are extremely rare, (b) Pleurisy 
can be distinguished on careful examination, (c) Meteor ism is at once 
excluded by filling the stomach or colon with water, (d) Diaphrag- 
matic hernia is very frequently confused with pneumothorax; out of 
433 cases collected by Grosser only 12 were recognized. The arrays 
will determine the condition, as in Dehio's recent case. Respiratory 
excursion is present and the tympany and metallic sounds are usually 
accompanied by such symptoms of marked incarceration as vomiting, 
colic, obstipation and indicanuria. The intestines push the heart to 
the right. Ninety per cent, of cases of diaphragmatic hernia are left- 
sided, (e) Pyopneumothorax subphrenicus (q. v. under Peritonitis, 
Localized Forms), especially described by Leyden, results from 



HYDROTHORAX 567 

abdominal lesions, such as cancer, ulcer, appendicitis, disease of the 
gall-tracts, trauma, and foreign bodies whose history is at least suggest- 
ive. Thoracic symptoms, as cough, sputum, and dyspnoea, are not 
conspicuous, at least early in the process, and the lungs may show 
perfect excursion, though the diaphragm is sometimes paretic. The 
manometer shows that the pressure is increased during inspiration and 
decreased during expiration, the converse of which is true in pneumo- 
thorax. The x-rays show that the diaphragm is above the fluid, while 
in pneumothorax it is below the fluid. 

Prognosis. — The prognosis varies with the cause, the condition of 
the lungs, and the character of the fluid, but it is always serious. Cases 
following exertion in a healthy lung, trauma or infarct (when operated) 
are relatively favorable. The closed and open are more auspicious 
than the valvular type. In tuberculosis, pneumothorax seems to arrest 
the tuberculous focus if it is small (Herard, Toussant, Fraentzel) and 
if no mixed infection occurs, but even in these cases complete ultimate 
recovery is infrequent. Eichhorst observed one case which lasted for 
five years. Gabb records a case which recovered and relapsed four 
times, the attacks being two to four years apart. According to Weil 
25 per cent, die within a week and 50 per cent, within a month; West 
observed a mortality of 70 per cent., of which three-quarters died 
within two weeks, nine-tenths in less than a month and one case in 
twenty minutes. 

Treatment. — The results of treatment are disappointing, (a) Nar- 
cotics and stimulants are imperative at the time of the rupture, for 
collapse, dyspnoea, and cyanosis, (b) Aspiration is of most value in 
the serous forms ; however, it has been said that we may tap or oper- 
ate but never aspirate, (c) The radical operation is indicated in 
putrid or purulent pneumothorax. Though some physicians prefer 
not to interfere in the tuberculous cases on the ground that the com- 
pression exerted upon the lung by the pneumothorax is semicurative, 
others advise operation; Leyden reported 66 per cent, and Richardiere 
50 per cent, of recoveries. 



(C). HYDROTHORAX. 

Definition. — Hydrothorax is a transudation of serous fluid into the 
pleural sac. 

Etiology. — (a) Stasis, from cardiac, pulmonary or vascular factors 
may be the cause. In failure of the right heart the superior cava is 
imperfectly drained, which congests the vena azygos and hemiazygos, 
and this leads in turn to pleural transudation. It may occur alone or 
precede dropsy but is oftener a part of general dropsy. Local venous 
obstruction, by pressure or thrombosis, may induce hydrothorax, as 
from mediastinal tumor or aneurysm. (6) Blood changes, resulting 
from multitudinous anaemic, marantic or cachectic states, may be 
causative; nephritis, cancer and blood diseases may be cited as specific 



568 DISEASES OF THE RESPIRATORY TRACT 

types. Under this caption may be brought diseases — often identical 
with the above — which alter the walls of the vessels. 

Symptoms and Diagnosis. — 1. The symptoms of hydrothorax do 
not include pain or fever. The disease accentuates, sometimes con- 
siderably, the dyspnoea attending the causal stasis or cachexia. The 
amount of fluid varies from«ounces to quarts (or even to two gallons). 

2. The physical signs are essentially those of moderate effusive 
pleurisy, except that the rub is absent; the fluid shifts with much 
greater facility on change of posture and produces a moderate com- 
pression of the lungs, and luxation of the heart, liver and spleen. The 
transudate is usually bilateral (in 83 per cent., according to J. Dutton 
Steele), but is sometimes unilateral and often right-sided, in cardiac, 
renal and hepatic disease, or when previous adhesions obliterate the 
opposite pleura. 

3. The fluid is clear, slightly green, possibly moderately blood-tinged 
if it develops during the death agony, and shows a specific gravity of 
about 1,010 to 1,012; it contains but little fibrin and at the most 
develops only light delicate flocculi. The potassium iodide test is 
unreliable (v. Diagnosis of Pleurisy), and centrifuging brings down 
only a few leukocytes, endothelial cells and red disks, but no bacteria. 
Right hydrothorax may prove very obstinate, probably because a low 
grade of inflammation eventually supervenes. 

The prognosis and treatment are those of the cause : aspiration often 
prolongs life. 

(D). HEMOTHORAX. 

Blood effusion into the pleura is a rare malady. It may be caused 
by trauma, scurvy or allied blood diseases, by rupture of aneurysm 
of the aorta, by ulceration of the pulmonary or pleural veins and by 
various necrosing lung diseases. It may occur with pleurisy and pneu- 
mothorax and has resulted from thoracocentesis. Its symptoms are 
essentially those of hydrothorax; it is suspected only by a sudden 
onset with signs of acute anaemia, and is proven only by the exploring 
needle. Its treatment is symptomatic; for the occasional syncope, the 
usual stimulants should be given; ice should be applied to the chest, 
ergot should be given, or a 2 per cent, gelatin solution should be in- 
jected for hsemostasis; and operation should be invoked when in- 
dicated bv the causal lesion. 



(E). CHYLOTHORAX. 

A very rare affection, in which true chvle or chyliform fluid is 
found in the pleura. Its etiology is much disputed; (a) in the genuine 
chylous cases true chyle containing sugar is found, though of late 
years sugar has been found in very many forms of serositis and in 
most transudates; only 30 cases of this type are recorded. In 11 



PLEURAL TUMORS 569 

cases (of which 4 died and of which 9 were right-sided), traumatic 
rupture of the thoracic duct has been found. In others the duct has 
been obstructed by thrombosis of the subclavian vein or by glands 
and tumors, (b) In a second group, the pseudochylous (chyliform or 
adipose), there is no chyle and the milky appearance is due to fatty 
globules or minute albuminous granules held in suspension. This 
variety is chiefly tuberculous or carcinomatous. It has been thought 
that old empyemas may become chyliform. The characters of both 
forms of fluids will be considered under chylous and adipose ascites, 
with which they are frequently associated. The signs are those of 
transudation or exudation. Sixty per cent, of cases occur on the right 
side. 

(F). PLEURAL TUMORS. 

Pleural tumors are nearly always secondary to pulmonary, medi- 
astinal or extrathoracic growths. Carcinoma and sarcoma are the most 
frequent forms; enchondroma and dermoids are very uncommon. 
The pleura is involved by contiguity or metastasis. Wagner, Fraenkel 
and Riedel described a primary endothelioma of the pleura, but, as 
stated under the etiology of pleurisy, it is considered by some as solely 
inflammatory; clinically it presents the picture of chronic pleurisy plus 
occasional metastatic deposits in the liver, lungs, kidneys, muscles 
and lymph glands. The signs are those of lung tumor plus those 
of pleurisy; the clinical diagnosis of primary tumor is at the best 
but probable, even if tumor particles are obtained by puncture or if 
a tumor develops at the seat of puncture. 



DISEASES OF THE MEDIASTINUM. 

(A). MEDIASTINAL TUMORS. 

Mediastinal tumors are very rare (1 in 10,000 medical cases). 
They are usually primary. Sarcoma is the most common form, and 
then carcinoma; lipoma, substernal struma, thymic growths, fibroma, 
osteoma, enchondroma, echinococcus, dermoid (57 cases collected by 
R. S. Morris previous to 1905), teratoma, gumma, tubercle, leukemic, 
pseudoleuksemic and chloromatous adenopathies are rarer forms. 
Sixty per cent, occurs in males between twenty and thirty years of age. 

Symptoms. — Symptoms develop gradually. (1). There may be local 
signs, (a) Bulging may be present in the jugulum or under and near 
the sternum, especially in lymphosarcoma, or it may show in the 
anterior mediastinum, and cause stretching of the skin, (b) There 



570 DISEASES OF THE RESPIRATORY TRACT 

may be pulsation, imparted by the heart, aorta or its branches, (c) The 
tumor or secondarily involved glands may be palpable deep in the jug- 
ular notch. The vocal fremitus varies, (d) The sternum may be ex- 
quisitely tender from erosion, (e) Dulness may be elicited under or 
near the sternum, or, if the posterior mediastinum is involved, in the 
back; the dulness may blend with the heart, suggesting aneurysm or 
effusive pericarditis, though it is more irregular than in either of 
these affections. (/) Auscultation gives variable results; sometimes 
there is bronchial breathing, or if the bronchi are closed the breath 
sounds may be absent. 

2. Compression symptoms, as in aneurysm, may predominate in tu- 
mors of the posterior and middle mediastinum, though local physical 
findings may be slight or absent, (a) The vagus and its branches may 
be affected. Paroxysmal asthma and orthopncea are common. Dysp- 
noea is the earliest and most frequent symptom of mediastinal tumor, 
is partly due to compression of the vagus, and partly to tracheal, cardiac 
and pleuritic involvement. Other vagus symptoms are brazen cough 
from paralysis of the vocal cords, tachy- or bradycardia, hiccough, 
vomiting or oesophageal spasm, (b) The trachea or bronchi may be 
compressed from without or may be occluded by ingrowth into their 
lumen, in which case the symptoms of tracheal or bronchial stenosis 
may be pronounced. Tracheal tugging and shrinking of one side 
of the chest (instead of bulging) may be noted. The sputum may 
contain blood, tumor tissue, or hair. The larynx may show lateral 
deviation, (c) The vessels may be involved. The arteries of the neck 
may show a systolic stenotic murmur, but the veins are more often 
compressed, especially the innominates or the superior cava, which 
cause bilateral or unilateral oedema and cyanosis of the face, neck 
and arms; enlargement of the veins on the thorax indicate the col- 
lateral circulation, (d) The heart may be compressed and dislocated, 
downward and outward if the growth emanates from the anterior 
mediastinum, forward if from the posterior mediastinum. Disloca- 
tion of the liver and spleen are less common, (e) The oesophagus 
may be so compressed and dysphagia may be so extreme that death 
from inanition results. (/) The sympathetic ganglia may show symp- 
toms; inequality in the pupils is uncommon, (g) Neuralgias, mus- 
cular paralysis or even spinal paraplegia may result. 

Diagnosis. — A diagnosis is either positive from the signs, or pre- 
sumptive from the symptoms. Dyspnoea, ectasia, irregular substernal 
dulness, venous stasis, bronchial stenosis, heart luxation and the x-rays 
picture make the diagnosis probable; puncture may both eliminate 
the possibility of aneurysm and withdraw tissue or dermoid material 
(Tiirck); the sputum sometimes voids tumor particles, hooklets, and 
hair. Deep aneurysm (v. Diagnosis of Aneurysm) is most difficult 
to eliminate. The irregular dulness and the apex beat at its extreme 
limit to the left exclude pericarditis. Tumors of the lung and pleura 
produce less pressure symptoms, though this differentiation is of less 
moment. 



MEDIASTINITIS 571 

Prognosis and Treatment. — The prognosis is unfavorable, as malig- 
nant growths cause rapid emaciation, and death from inanition, com- 
pression, exhaustion or pneumonia results within a few months. Benign 
tumors run a longer course, sometimes five to seven years, or even 
forty in Lebert's dermoid case. Treatment is palliative. A few 
successful operations are reported; in twenty operated cases of der- 
moid, 70 per cent, recovered (R. S. Morris). 



(B). MEDIASTINITIS. 

Acute inflammation is uncommon, but may follow various local 
lesions, as pleurisy, pericarditis, pneumonia, acute lymphadenitis and 
kindred processes (v. Mediastinal Pleurisy) by contiguity or by 
metastasis, (a) Acute nonsuppurative cases begin with chill, fever, 
pain in the mediastinum and tenderness anteriorly over the sternum or 
high in the back; there may be oedema over the sternum; dysphagia, 
dyspnoea and vague cardiac symptoms may develop. The diagnosis 
is difficult, but a presumptive diagnosis is made from acute inflam- 
matory symptoms with mediastinal localization. The prognosis is 
grave and the treatment is symptomatic; an ice-bag should be applied 
over the sternum and opiates should be given for pain, (b) Of medi- 
astinal abscess, Hare (Prize Essay on Mediastinal Disease, 1889) col- 
lected 115 cases, in most of which the anterior mediastinum was 
affected. They occurred chiefly in males. Acute cases, which are 
most often traumatic or sequential to the eruptive diseases, were found 
more frequently than chronic cases, which were usually tuberculous 
(v. Mediastinal Pleurisy). 

Symptoms. — The symptoms are local (mediastinal), as in simple 
acute mediastinitis, and general (septic). A throbbing retrosternal 
pain is common and dyspnoea may result from pressure by large pus 
pockets. (Edema, fluctuation and pointing in the upper interspaces 
or in the jugular notch may be noted. Fatal hemorrhage may follow 
simultaneous erosion of the aorta and bronchus. External rupture 
may occur in the second interspace (Daude) or internal rupture into 
the air passages, bloodvessels, oesophagus or pleura; deep burrowing 
to the abdomen has occurred. The exploring needle is of great diag- 
nostic aid in doubtful cases. Operation is indicated: Auvray (1904) 
found in the literature, 36 operations with 33 recoveries. 

(c) Chronic mediastinitis (mediastinopericarditis) is discussed under 
adhesive pericarditis. 



(C). MEDIASTINAL HEMORRHAGE. 

Small hemorrhages of no clinical importance may result from " blood 
dissolution," as in icterus, hemorrhagic blood diseases or acute infec- 



572 DISEASES OF THE RESPIRATORY TRACT 

tions. Larger hemorrhages may follow trauma or erosion of the large 
vessels, both of which usually overshadow the mediastinal incident. 



(D). INTERSTITIAL EMPHYSEMA. 

(See DlFFEKENTIATION OF EMPHYSEMA.) 



SECTION IV. 



DISEASES OF THE DIGESTIVE TRACT, 



DISEASES OF THE MOUTH. 

(A). CATARRHAL STOMATITIS. 

Etiology. — Simple, acute or erythematous stomatitis is the most 
frequent form. In children it may develop with dentition, improper 
feeding, rude cleansing of the mouth, and digestive disorders, especially 
in those who are poorly nourished; it is part of various infections, 
notably of the exanthemata and syphilis. In adults it results from 
thermal, mechanical and chemical irritants; hot food, alcohol, tobacco, 
various chemicals (iodine, mercury, arsenic, copper, etc.), acidulous 
vomiting, inflammatory extension from the salivary glands, carious 
teeth, nose and throat disease, uncleanliness, anaemias and stasis are 
among its causal factors. 

Symptoms. — Symptoms are chiefly redness, swelling and increased 
secretion, and in the acute forms burning pain which makes eating 
difficult. The increased saliva is usually acid and irritates the lips 
or chin if it flows over them. The gums are turgid (gingivitis) and the 
tongue broadened, lax and therefore indented by the teeth, as is also 
the buccal mucosa. The tongue is generally coated. Vesicles some- 
times form and break down into small erosions which heal with cica- 
trices. The whitish areas sometimes seen are epithelial thickening. 
Fever, thirst and general symptoms are absent, except in some infantile 
cases. Acute stomatitis lasts but a week or two, but may become 
chronic. Transient stomatitis is almost physiological in the new-born. 

Treatment. — In children the mouth should be gently washed after 
each nursing. Cold water or ice mitigates pain. Boracic acid is excel- 

573 



574 DISEASES OF THE DIGESTIVE TRACT 

lent and safe. In adults the teeth should be cared for. Tincture of 
myrrh and tincture of rhatany — equal parts — are excellent astringents. 
Stronger antiseptics may be used in adults but are dangerous in 
children, who may swallow them; for instance, 2 per cent, sodium 
salicylate, 2 per cent, chlorate of potash, 1 per cent, carbolic solution; 
erosions may be touched with 1 per cent, silver nitrate. 



(B). STOMATITIS ULCEROSA. 

Etiology. — Though probably a mycotic affection, its bacteriology is 
unknown. In some cases the same microorganisms are found as in Vin- 
cent's angina (See Diagnosis of Diphtheria and Acute Pharyn- 
gitis). Sporadic cases are more common than epidemics, which 
may occur in asylums or prisons. It may be induced by malnutrition, 
uncleanliness, oral or dental disease, phthisis, leukaemia, diabetes, toxic 
factors (principally mercury), and occurs especially at dentition and 
more in city than in country children. 

Symptoms. — The symptoms are those of catarrhal stomatitis plus 
necrosis and then ulceration. The gums, especially about the incisors 
and canines, are red, swollen, loose and spongy; they bleed readily, 
secrete pus and ulcerate; over the ulcers a membrane develops. The 
teeth are exposed, loosened and perhaps fall out. Necrosis of the jaw 
sometimes results. The tongue and cheek ulcerate less often and the 
pharynx is nearly exempt. The breath is foetid, the saliva is increased, 
the submaxillary lymph glands and the salivary glands are swollen 
and mastication is almost impossible. Fever, prostration and signs 
of sepsis, as erythema, chills, and rapid pulse, may mark the severest 
cases. Acute cases last one to two weeks and chronic cases weeks or 
months. 

Varieties. — (a) Mercurial stomatitis may occur in workers in the 
metals or from clinical administration. The author saw a hospital 
case of nephritis in which one dose of five grains of calomel caused 
necrosis of the entire tongue, which rotted off at its root (See intoxi- 
cations). Mercurial and other stomatitis may cause " erosions " of the 
enamel in the developing teeth of children; they become pitted, dis- 
colored and transversely furrowed, (b) Riga's disease, described by 
Riga (1881) in South Italy, is an affection in which there is a pearly 
induration which occurs only between the tip of the tongue and the 
frsenum, appears with the first dentition, sometimes ulcerates, is 
occasionally epidemic, is often observed with the status lymphaticus 
and is invariably fatal, (c) In nursing women, ulcers, 3 to 4 mm. 
in diameter, may develop from the lymph follicles of the lip and cheek ; 
they usually indicate malnutrition, sometimes are quite painful, and 
respond to general tonics and hygiene, (d) Herpetic or pemphigoid 
stomatitis is seen in neurotics (Jacobi's stomatitis chronica neurotica) 
and is frequently recurrent, (e) Bednar described (aphthous) white 
plaques on the posterior part of the hard palate near the alveolar border 



APHTHOUS STOMATITIS 575 

of the upper jaw, which may ulcerate; they occur in the first three 
months of life, and are apparently due to sucking, are not syphilitic, 
and are ominous only in marantic children. (/) Parrot's ulcers occur 
in the new-born on the hard palate near the median line; they occur 
in marantic children and seldom heal. 

Treatment. — Treatment includes that of catarrhal stomatitis. Po- 
tassium permanganate 1 to 1,000 relieves the jcetor ex ore. Necrotic 
areas may be touched with silver nitrate solution or equal parts of 
tincture of the chloride of iron and glycerine. Potassium chlorate 
gargles may be combined in children with gr. x to xx of the drug every 
day internally and twice the amount for adults, but it must be re- 
membered that toxic effects may result. Opium and belladonna are 
used in severe cases for pain and salivation. 



(C). APHTHOUS STOMATITIS. 

Etiology. — It may occur alone or with fevers and other diseases, 
sporadically or epidemically. It is probably contagious but its nature 
is still undetermined; it is classed by some with impetigo, due to the 
staphylococcus, and by others with foot-and-mouth disease; when 
due to milk it ceases on withdrawal of the milk. Besides the general 
causes of stomatitis (v. s.), it occurs chiefly in children between ten 
and thirty months old. 

Symptoms. — Symptoms begin with restlessness, slight fever, thirst, 
salivation and pain in the mouth. Round, yellow-white and slightly 
elevated areas as large as a pea appear on the surface and edges of the 
tongue and less often on the lip and buccal mucous membrane. The 
mucosa is slightly reddened about them. They cannot be scraped off 
and attempts to do so produce bleeding. Pathologically they are 
areas of superficial necrosis, into which exudation of fibrin and round 
cells occurs (stomatitis fibrinosa disseminata). Vesicles are described 
but seem to be no part of the process, though they may occur on the 
skin near the mouth. Occasionally there is tumefaction of the lym- 
phatic and salivary glands. Their clinical evolution is rapid; they 
last one to two weeks, and recurrence is frequent. The treatment is 
that of stomatitis. 



(D). PARASITIC STOMATITIS. 

Etiology. — Thrush, muguet, soor, or stomatomycosis oidica is due to 
the Oi'dium albicans, closely allied to the saccharomyces, which con- 
sists of branching mycelia and ovoid granular and refracting spores. 
It occurs chiefly in very young children whose mouths have been im- 
properly cared for, or who have stomatitis and reduced nutrition. It 
prevails especially among the poor and in institutions. Dirty nipples 
are probably the most frequent mode of inoculation. Thrush may 



576 DISEASES OF THE DIGESTIVE TRACT 

develop in adults, as in weakly convalescents, or in tuberculous and 
diabetic subjects. 

Symptoms. — A few thin, punctate, whitish spots develop on the 
tongue, cheek and soft palate; they become yellowish as the areas 
grow or fuse. The fungus is at first deposited on the epithelium, be- 
tween the layers of which it proliferates and penetrates. The mouth 
is dry, or, with diffuse stomatitis, is moist from increased salivary flow. 
In the more severe cases the fungus may reach the pharynx, larynx, 
oesophagus, and even the stomach and intestine. Its deposit is gen- 
erally limited to areas with flat epithelium, and epithelia of the cylin- 
drical and ciliated order usually escape. It may, in exceptional cases, 
cause oesophageal occlusion, or bronchopneumonia; or by unusually 
deep penetration to the submucous vessels it may cause cerebral, renal 
and other embolism. The outlook is good except in marantic subjects. 

Treatment. — Prophylaxis is most essential in regard to cleansing 
of the mouth, sterilization of bottles and nipples, and maintenance of 
the general health by fresh air and by early treatment of dyspeptic dis- 
orders. In some cases the stomatitis persists until a wet-nurse is 
substituted for the feeding with cow's milk. Cleansing the mouth with 
borax, boric acid, sodium bicarbonate and lime water is most effective. 
If unusual extension occurs, a teaspoonful of a resorcin solution (1 to 
100 or 300 parts) may be given every two hours. 

Stomatitis may in rare cases result from other parasites, as the sar- 
cina or leptothrix, and from such bacteria as the pneumococcus, gono- 
coccus, Friedlander's bacillus, etc. 



(E). GANGRENOUS STOMATITIS. * 

Etiology. — "Gangrene of the cheek," noma or cancrum oris, is a 
rare affection. Age: of B run's 415 cases, only 11 occurred in 
persons over fifteen years of age and only 6 in infants. The author 
recently saw a case in a man forty years old, which was fatal on the 
fifth day. Sex: more cases occur in girls than in boys. Malnutrition 
and neglect are causes of some cases, and others follow acute infec- 
tions; 50 per cent, follows measles; typhoid, scarlatina, etc., are less 
frequent factors. A bacillus resembling that of diphtheria has been 
isolated (Bac. necroseos). Cladothrix threads similar to those in Vin- 
cent's angina may be seen. 

Symptoms. — Symptoms usually begin with ulceration of the gums 
or buccal mucosa near the angle of the mouth. Rapid necrosis and 
gangrene follow with extensive brawny oedema of the face. The fcetor 
is intense and much tissue is frequently sloughed off. Perforation of 
the cheek, necrosis of the jaw and extension to the throat, orbit or 
ears are not uncommon. Seventy per cent, of cases die within a week; 
they show septic symptoms, such as high fever, weak heart, prostra- 
tion, diarrhoea, colitis, and meningitis, or symptoms of lobular pneumonia 



ECZEMA 577 

becoming gangrenous. The other cases exhibit less general reaction 
and may leave only an extensive scar or fistula on the cheek. The 
mortality was 92 per cent, in Springer's collation. 

Treatment. — Treatment is ineffectual. A full diet and free exhibi- 
tion of alcohol are indicated as in sepsis, and disinfectants should be 
applied to the necrotic focus; local measures as excision, the live 
cautery and caustics are employed, usually without success, and some- 
times with aggravation of the necrosis. 



DISEASES OF THE TONGUE. 

(A). ECZEMA. 

In eczema the epithelium thickens and desquamates, leaving red- 
dish, smooth and circular, serpiginous or geographical areas, which 
heal centrally and extend peripherally. It may cause local irritation or 
worry to the patient, who may think he has syphilis or cancer. Again, 
it is an accidental finding on the tongue or cheeks. Its cause is un- 
known, its course is quite chronic, and its treatment by silver nitrate 
is quite inadequate. 

(B). LEUKOPLAKIA. 

Leukoplakia (psoriasis, ichthyosis, keratosis) is an affection closely 
resembling the "geographical tongue/' in connection with which it 
is often described. Irregularly-shaped, smooth, pale plaques, measur- 
ing one to two centimeters, develop on the tongue and less often on 
the lips, cheek or tonsils; they consist of thickened epithelium. Eighty 
per cent, of cases occur in men (98 per cent., Fournier); the use of 
tobacco and alcohol, and gout and gastric disease are probable factors; 
syphilis is not a cause and antisyphilitic remedies are directly injurious, 
though Fournier's experience with 324 cases convinced him that 80 
per cent, came from syphilis and 20 per cent, from tobacco. Its symp- 
toms are not marked, its course is very chronic and its treatment is 
nearly always without results. Ten per cent, solutions of sodium 
salicylate; chromic acid, 5 per cent.; strong silver nitrate applications, 
especially to fissured places; corrosive sublimate (1 to 500 parts) and 
the galvanocautery are recommended. Excision is necessary for papil- 
lomatous or epitheliomatous outgrowths, which are said to develop 
in one-third to nearly one-half the cases. 



37 



578 DISEASES OF THE DIGESTIVE TRACT 



(C). ACUTE GLOSSITIS. 

Acute glossitis may be localized or diffuse, and usually ends in sup- 
puration. It follows stings, burns, erosions or the entrance of pyogenic 
cocci through the lymph follicles. The tongue is swollen, sometimes 
so greatly that it protrudes beyond the lips, and is painful. Eating, 
and even speaking or oral breathing are impossible. Early scarifica- 
tion and later incision of purulent foci are indicated. 

(D). GLOSSITIS DESICCANS. 

Glossitis desiccans is a rare, chronic, intractable affection in which 
deep indentations of the margins of the tongue, and consequent lobula- 
tion occur. Melanoglossia (nigrities linguce) results from proliferation 
of the filiform papillae at the base of the tongue, which appear like hair 
(melanotrichia linguce, black-haired tongue); they are removed by a 
10 per cent, salicylic acid solution or by curetting. The mucor niger 
may^cause a black coating on the tongue. 






DISEASES OF THE SALIVARY GLANDS. 

(A). PTYALISM, SALIVATION, HYPERSECRETION, SIALORRHCEA. 

Etiology. — The chief causes are (a) disease of the mouth, stomatitis, 
dentition; (b) toxic substances as jaborandi, tobacco, physostigma, 
digitalis, mercury, iodides and various metals; (c) nervous affections, 
as trigeminal neuralgia, diseases of the pons and medulla, paretic 
dementia, hypochondriasis, and hydrophobia; a close distinction 
should be drawn between oversecretion and lesions in which, like 
bulbar paralysis, the saliva cannot be swallowed; (d) reflex salivation, 
which may also occur from diseases of the tympanum through the 
chorda tympani, from gastro-intestinal disease (gastric ulcer, pancre- 
atic lesions, etc.) by way of the vagus and sympathetic nerves, and from 
genital conditions, as pregnancy. 

Symptoms. — The physiological salivary flow measures seven ounces 
to three pints (200 to 1500 c. c), which pathologically may amount to 
quarts; a flow of over twelve quarts has been recorded. The salivary 
glands are tense, swollen, and even hard. The reaction of the saliva 
may become neutral or acid; it is chiefly thin and fluid, but may con- 
tain some ropy mucus or scattered pus cells; the ptyalin disappears 
together with the potassium sulphocyanide. The saliva may trickle 



XEROSTOMIA 579 

into the larynx during sleep, and thus cause violent coughing; it may 
flow into the stomach, and produce vomiting, of an alkaline or neutral 
vomitus, especially in the morning; it may stream from the lips, and 
cause the adjacent skin to become erythematous. 

Prognosis and Treatment. — The prognosis depends wholly on the 
causal affections, whose operation may be transient, intermittent or 
permanent. Treatment is likewise causal. Any toxic cause should be 
removed. In nervous and reflex types, potassium bromide is often 
valuable and the iodides are sometimes efficacious in pregnancy. The 
more severe cases necessitate opium and occasional doses of bella- 
donna. 

(B). XEROSTOMIA. 

Hyposecretion or arrested secretion was first described by Jonathan 
Hutchinson. Besides its occurrence, as a result of atropine and allied 
remedies, it occurs in diabetes insipidus and mellitus, in some cases of 
contracted kidney, and finally, as an independent neurosis or a neurotic 
symptom. Women (80 per cent.) are affected more often than men. 
The tongue and mouth are dry, red and glistening, which may render 
speaking, chewing and swallowing most difficult. The tongue may 
cleave to the roof of the mouth. The digestion of carbohydrates is 
impaired. Treatment consists in painting the mouth with iodine, 
potassium iodide and glycerine (1, 10, 100 parts respectively), the ad- 
ministration of pilocarpine hydrochlorate h to h of a grain and galvanic 
applications to the parotid. 



(C). PAROTITIS. < 

Besides acute specific parotitis (mumps), infection may reach the 
parotid or other salivary glands by way of the blood stream or by 
infection entering their ducts. Acute parotitis may be simple but is 
oftener suppurative, the staphylococcus being the most common pyo- 
genic organism, (a) Any of the acute infections may be complicated by 
parotitis, of which typhoid is the most common ; parotitis may develop 
in measles, scarlatina, pneumonia, septicopyemia, and syphilis, (b) 
Diseases or trauma of the abdominal or pelvic structures are some- 
times complicated by acute parotitis, to which Paget drew special 
attention; they include diseases of or operations on the alimentary and 
genito-urinary tracts, peritoneal disease, pancreatitis, trauma to the 
abdominal viscera, which may result from pessaries or from external 
violence, injury of the abdominal wall, etc.; many of these cases are 
clearly attenuated sepsis. Wagner, in 1904 was able to collect 61 cases 
of postoperative parotitis; 31 were operations upon the genitalia; he 
believes the cause is not hematogenous infection, but an infection 
ascending along the duct from the mouth, (c) A rare form of acute 
parotitis in facial neuritis is described by Gowers. 



580 DISEASES OF THE DIGESTIVE TRACT 

Chronic parotitis sometimes follows epidemic or symptomatic paro- 
titis; it may occur in poisoning by mercury or lead, and in syphilis or 
chronic nephritis. The parotid is usually painless, though it is 
sometimes both painful and tender. Mikulicz has described a " chronic 
symmetrical hypertrophy of the salivary and lachrymal glands " which 
is often of long duration. 

Treatment. — In acute parotitis, local derivants as leeches, the early 
application of cold and the later use of hot fomentations, and finally 
of surgical incision, if there is pus formation, are indicated. Chronic 
forms respond slowly to treatment; iodine or mercurial ointments 
should be employed. Iodide is useful in Milkulicz's disease. 

The parotid gland and its duct may become inflated with air in 
persons having such occupations as blowing wind-instruments or in 
glass-blowing. In rare cases gas forms in the gland or its duct. 



(D). ANGINA LUDOVICI. 

Ludwig's angina is generally due to a streptococcic infection begin- 
ning in the submaxillary gland, and extending to the floor of the mouth 
and to the cervical cellular tissue. In some cases no promoting cause 
is found, or trauma may be its immediate antecedent, but most cases 
are secondary to typhoid, diphtheria, scarlatina and kindred acute 
infections. It is the analogue, though differing in location, of acute 
phlegmon of the pharynx and larynx (submucous suppurative inflam- 
mation or oedema). The streptococcic inflammation spreads rapidly, 
causing fever, redness, pain and swelling under the tongue, cellulitis 
and sometimes gangrene in the neck (cynanche gangrceneuse). Masti- 
cation and deglutition may be impossible and glottis oedema is not 
infrequent. The parotids are sometimes invaded. Resolution is very 
exceptional and external pointing of pus is not likely to occur, whence, 
without early surgical intervention, septic and pysemic complications 
or laryngeal and pharyngeal oedema or phlegmon very frequently 
develop. 

(E). SIALODOCHITIS FIBRINOSA. 

Inflammation of the salivary ducts with formation of membrane 
(Kussmaul) results from infection ascending from the oral cavity and 
is characterized by fever and tenderness, pain and tumefaction of the 
salivary gland, due to retained secretion and infection. The duct is 
kept patent by pressure or sounding. 



(F). SIALOLITHIASIS. 

Stones of calcium phosphate or carbonate occur more frequently in 
Wharton's duct than in the other salivary ducts. Their usual cause is 






ACUTE PHARYNGITIS 581 

stagnation of the salivary secretion by foreign bodies, bacterial or 
fungus invasion or mechanical stricture following ulceration. Roberg 
(1904) found stones in Wharton's duct fifty times, in the submaxillary 
gland twenty-eight times, in Stenson's duct six times and in the parotid 
gland twice. 



DISEASES OF THE PHAEYNX. 

(A). ACUTE PHARYNGITIS. 

Etiology. — Acute, superficial, simple angina may be caused by (a) 
rheumatism, cold or exposure; (6) infections, either acute (measles, 
scarlatina, variola) or chronic (malaria or syphilis); (c) gout, dyspep- 
sia, or smoking; (d) in many cases the cause is obscure; though pro- 
bably always mycotic, no one germ is especially found. It is most 
common in youth. 

Symptoms. — (a) Local: — The throat is red, glazed and streaked with 
mucopus which is easily wiped away. The soft palate and uvula are 
sometimes swollen; superficial erosions, small vesicles on the palate 
and swollen mucous follicles are occasionally seen. In some cases the 
local findings, especially when hidden in the nasopharynx, are very 
slight in proportion to the local pain and general symptoms. There is a 
scratching, tickling sensation in the throat which may radiate into the 
posterior nares or into the ear. The patient hawks, but raises little, 
unless there is coincident rhinitis or laryngitis. Swallowing is rather 
painful, slight deafness is quite common, the speech is sometimes 
slightly nasal, and the angular lymph nodes are painful and tender. 
(b) Constitutional symptoms are usually slight. At the onset there are 
chilliness, moderate fever, aching in the muscles and in some individ- 
uals extreme cutaneous hyperesthesia, which, on superficial examina- 
tion, may be falsely attributed to changes in the deeper parts of the 
body. With or without coincident tonsillitis, there ma v , be high fever, 
and in labile individuals, marked nervous intoxication. Herpes facialis 
occasionally develops. Complications, as acute endocarditis, or 
nephritis, are very uncommon. In a few days the process is complete 
and convalescence is rapid. 

Treatment. — (a) Local: — painting the entire pharynx with a 20 
per cent, silver nitrate solution usually affords not only local but 
general relief. (6) General: — Dover's powder aid aspirin, each ten 
grains, may be exhibited for unusual pain, aconite for high fever, calo- 
mel, followed by salines, for elimination, and a 1 per cent, solution 
of carbolic acid for the irritated throat. 

The pneumococcic sore throat may be suppurative, pseudodiphther- 
itic, follicular (like tonsillitis), erythematous or herpetiform; its onset 



582 DISEASES OF THE DIGESTIVE TRACT 

is severe, like that of pneumonia, it produces a thicker, denser and 
more adherent membrane than does the streptococcus and the prog- 
nosis is generally poor. 

(B). CHRONIC PHARYNGITIS. 

Etiology. — The causes are: (a) repeated acute pharyngitis; (b) 
excessive smoking or use of alcohol; (c) abuse or over-use of the 
voice, as in clergymen, vendors, etc; (d) extension from or association 
with chronic nasopharyngitis or laryngitis; (e) various conditions of 
the blood, as in chronic nephritis, syphilis, arthritism, etc. These 
causal factors are most common in adolescence and middle life. 

Symptoms. — The symptoms are local. The mucosa of the naso- 
pharynx is generally red and lined with turgid venules; the pillars and 
uvula are relaxed, and the drooping uvula may occasion tickling of the 
tongue or even of the epiglottis, thus causing chronic coughing. The 
sides of the pharynx may show isolated whitish areas of epithelial 
thickening or more often small, round, reddish, hypertrophied lymph 
follicles (pharyngitis granulosa), sometimes in linear distribution. 
The pharynx is dry and burning, exciting hawking efforts which are 
not only unproductive but in themselves are irritating to the pharynx 
and may cause morning vomiting. The mucous glands are at times 
hyperplastic. Slight bleeding occasionally causes unnecessary worry. 
Middle ear involvement is common, through the Eustachian tube. 
Pharyngitis sicca is an atrophic type, analogous to rhinitis sicca 
(atrophica) and marked by a pallid glazing, chiefly of the posterior 
pharyngeal wall, and by formation of crusts. 

Treatment. — (a) The causal factors, as improper straining or 
tension of the voice in speaking, excessive alcoholism or smoking, etc. 
should be corrected respectively, by rest and avoiding irritant foods or 
stimulants. Alkaline laxatives are frequently beneficial. (6) Galvano- 
puncture of the turgid veins or hyperplastic follicles is indicated; 
marked improvement is probably more frequent than aggravation of 
the condition by over-zealous treatment, (c) Local medical treatment 
is less efficacious, as 2 to 20 per cent, solution of tannin in glycerine, 
equal parts of tr. ferri chloridi and chlorate of potash, 1 to 5 per 
cent, solution of chloride of zinc, or 2 to 20 per cent, nitrate of silver 
solution. 

Acidi carbolici gr. xx. 

Acidi tannici 5ss. 

Aluminis 5j. 

Glycerini gij. 

Aquae rosae q.s. ad §v. 

M. et ft. gargarismus. 
S. — As gargle, properly diluted. 

(d) For dry atrophic pharyngitis, iodine, potassium iodide and gly- 
cerine (1:10:100 parts, respectively), massaged thoroughly into the 
pharynx, is the best known measure: 



RETROPHARYNGEAL ABSCESS 583 

Iodi gr. iij, 

Potassii iodidi 3ss. 

Glycerini Bj. 

M. et S. — Locally. 

(C). PHLEGMONOUS PHARYNGITIS. 

Angina phlegmonosa, especially described by Senator, is not super- 
ficial as is simple pharyngitis, but invades the submucosa. It is usually 
primary but may be metastatic from distant suppuration. The throat 
is painful, swollen and cedematous, the neck enlarges and suppuration 
occurs with high fever, septic symptoms and difficulty in swallowing 
and breathing, especially when the subject lies down. The inflamma- 
tion may be hemorrhagic or necrotic. Phlegmonous angina is the 
analogue of suppurative submucous laryngitis and of angina Ludovici. 
Without surgical intervention or early spontaneous rupture into the 
throat, death occurs from septicopyemia, mediastinitis or from oedema 
of the glottis. 

(D). RETROPHARYNGEAL ABSCESS. 

Various forms are described, (a) The primary form occurs in chil- 
dren under two years of age; the early symptoms are dysphagia, a 
nasal voice and retropharyngeal suppuration, either as a visible pro- 
trusion on the posterior pharyngeal wall or as a palpable fluctuation 
there; in a week or two dyspnoea, cyanosis and inspiratory retraction 
of the chest develop. It is a primary lymphadenitis, (b) Secondary 
typ'es are less common in (i) caries of the cervical spine, (ii) diphtheria, 
erysipelas, scarlatina and (Hi) suppurative inflammation in the retro- 
pharyngeal lymph glands. The secondary type is caused by infection 
travelling along the lymph vessels, or rarely by metastasis. Unless 
surgical measures are instituted or spontaneous rupture occurs early, 
death occurs from asphyxia, mediastinitis, glottis stenosis, inhalation 
pneumonia or sepsis. After incision the head should be promptly 
thrown well forward to obviate occlusion of the air passages. 

(E). PHARYNGEAL ULCERATION. 

Syphilitic and tuberculous ulceration have been considered. Follic- 
ular ulcers are superficial and small and, like all ulcers in the mucous 
membrane only, heal without a cicatrix. Ulceration also occurs in 
diphtheria and the diphtheroid group, due chiefly to the streptococcus. 
Malignancy too, causes ulceration. Cancer and tuberculosis are us- 
ually diagnosticated with ease, and syphilis is separated ex juvantibus 
by the use of mercury and iodides in doubtful cases. 

Vincent's angina is discussed under Diagnosis of Diphtheria; 
according to Vincent, it constitutes two per cent, of all anginas including 



584 DISEASES OF THE DIGESTIVE TRACT 

diphtheria. It occurs especially in children between six and ten 
years of age and in medical students and servants in anatomical labora- 
tories, between the years of eighteen and thirty. Tobacco, scurvy, 
anaemia, tuberculosis, syphilis, scarlatina, measles and the eruption of 
the wisdom teeth are predisposing factors. The two causative organ- 
isms were first described by Rauchfus (1893); (a) the fusiform bacillus 
has pointed, sometimes rounded ends, is sometimes bent, measures six to 
twelve fji in length and may be flagellated; (b) the spirillum or spir- 
ochete is long, delicate, twisted and always occurs in severe forms. 
They stain with carbol-fuchsin but not by Gram's method. 

Symptoms. — (1) In the first period, there is congestion and oedema. 
(2) In the second stage, a grayish yellow membrane forms which is 
thick, friable and cheesy and is usually removable. (3) Under the 
membrane, an ulcer develops; it is usually single, round or oval and 
has an irregular edge, an uneven granulating floor and seldom any 
extension laterally. 

The general symptoms are lassitude, indigestion, vomiting or epi- 
staxis; fever is uncommon and complications rare (albuminuria, en- 
teritis or noma). Syphilis and diphtheria require differentiation. The 
affection heals in one-half to seven weeks, under applications of iodine 
locally, pencilling with silver nitrate, gargles of hydrogen peroxide or 
chlorate of potash internally. 



DISEASES OF THE TONSILS. 

(A). ACUTE FOLLICULAR OR LACUNAR TONSILLITIS. 

Definition. — An acute, largely parenchymatous, inflammation of the 
tonsils, due to local mycotic invasion and marked usually by decided 
constitutional reaction. 

Etiology. — (a) Bacteriologically , the streptococcus is the most fre- 
quent cause, though the staphylococcus and Fraenkel's diplococcus are 
also encountered; it is claimed that somewhat attenuated diphtheria 
bacilli are found, particularly at the time of diphtheria epidemics, but 
in such cases it is more correct to consider it as a sub-type of diphtheria 
(q. v.). (6) The still unknown virus of rheumatism is thought to gain 
access to the blood by way of the tonsils or pharynx ; affections com- 
monly regarded as associated with rheumatism, as erythema nodosum, 
chorea, and some forms of endocarditis, may follow acute tonsillitis 
(Packard). Tonsillitis may begin the rheumatic cycle, as described 
under rheumatism in children, or it may appear later in the rheu- 
matic process, with endocarditis, pericarditis, arthritis, and chorea. 
Endemics and the spread of the disease through a household or institu- 



ACUTE FOLLICULAR OR LACUNAR TONSILLITIS 585 

tion strengthen the theory that tonsillitis is an acute contagion, (c) 
Cold and dampness are directly predisposing causes; these conditions 
obtain in the United States largely in the spring, in some other countries 
largely in the fall months, (d) Tonsillitis occurs chiefly in youth and 
adolescence; infants are seldom affected, (e) Individual predisposition 
depends on some unknown factor and tonsillitis itself is of etiological 
importance, for one attack may induce recurrence. (/) Poor hygiene 
and possibly sexual activity, especially in young married people 
(Shepard), may be conducive to tonsillitis. 

Symptoms. — (a) The onset occurs with chilliness or rigor, severe 
pains in the bach and limbs, fever, rising within a day to 103 or even 
to 106 degrees in children or susceptible adults, pain in the throat, 
particularly on swallowing, and tenderness of the glands at the angle 
of the jaw. (b) Local findings: — the tonsils are swollen and soon show 
on the deeply injected surface three to ten yellowish- white or creamy 
points, corresponding to the crypts or lacunae; the crypts contain bac- 
teria, epithelium, leukocytes and sometimes cholestearin or fatty 
needles and are essentially small abscesses. Pathologically the tonsil 
is the seat of serocellular infiltration. Occasionally there are small 
superficial areas of necrosis, slight erosions or even formation of mem- 
brane. The voice may acquire a somewhat nasal twang, the pain 
increases for a few days and the angular glands remain both painful 
and tender, whence the head is often held rigidly forward and the jaws 
are opened only with difficulty. Pain in the ear is not uncommon, (c) 
The chief constitutional symptoms have been considered under (a). 
Anorexia, heavily coated tongue, feverish breath, hypersesthetic skin, 
marked depression, accelerated pulse and respiration, are common. In 
some cases the systemic symptoms are disproportionately severe and 
children, as well as some adults, may exhibit delirium; in two cases 
seen by the writer, in adults, retraction of the neck with headache, 
delirium and vomiting was thought indicative of meningitis. Herpes 
facialis is quite frequent. 

Complications. — Complications are not common. Acute pericar- 
ditis, endocarditis or nephritis may develop. Functional heart mur- 
murs, febrile albuminuria and erythema (from the toxins or from 
medication) are not very infrequent. As a rule, however, convalescence 
is complete within a week, though marked prostration and considerable 
residual swelling remain for some time. Repeated attacks may cause 
nephritis or endocarditis. 

Diagnosis. — The typical case cannot be confused, (a) Diphtheria 
produces a membrane, more whitish in color, which has an almost 
pathognomonic tendency to spread to the uvula, soft palate or pharynx; 
it leaves bleeding raw points when it is stripped off; it recurs after 
removal; it sometimes extends to the larynx; it is followed not infre- 
quently by paralysis, which almost never results from tonsillitis; it 
responds with more or less promptness to serotherapy, and shows in 
practically all cases the Klebs-Loeffler bacillus, (b) Tonsillitis nccro- 
tica leaves an ulcer; its bacteriology is disputed, some cases showing 



586 DISEASES OF THE DIGESTIVE TRACT 

the fusiform bacillus and spirilla of Vincent (see Ulcerative Pharyn- 
gitis and Diphtheria), and others are alleged to be due to the Bacil- 
lus diphtherias; in some cases there is much fever; in others none; 
the general reaction is severe, (c) The possibility of incipient scarlatina 
should always be kept in mind. 

Treatmeflt. — 1. Prevention. — The subject should be hardened by 
cool baths or sponges, and tonsillotomy should be performed. Douch- 
ing of the nose and gargling with Dobell's solution should be part of the 
daily toilet. 

2. Local Measures. — Though many local remedies are recom- 
mended, the best in the author's experience is silver nitrate; after 
cocainizing the throat, a small probe is bent at right angles near its end 
and introduced into each swollen crypt in order to puncture it and 
secure free drainage; then Dobell's solution should be applied, un- 
diluted, on small bits of cotton in each crypt; this is followed by 20 per 
cent, silver nitrate solution ; the results are often immediate, sometimes 
aborting the attack. Squeezing out the crypts with a spatula is ex- 
tremely painful but relieves the patient when the physician has no 
probe at hand. Hot water or hot fomentations may be applied to the 
neck. 

3. Constitutional Treatment. — In a relatively small number of cases 
sodium salicylate, given as in rheumatism, affords relief. Hydrargyri 
biniodide gr. 500 given every fifteen minutes for ten doses often aborts 
the process. Guaiac, though generally used, has produced unsatisfac- 
tory results in personal experience; the dose is tr. guaiaci ammoniat. 
tt£ x to xl every two hours. Aspirin, and Dover's powder aa gr. x, 
relieve pain in the throat, body, and limbs. Aconite and belladonna 
are often beneficial in children with high fever, and rather less so in 
adults; they are given as in coryza or influenza. 



(B). SUPPURATIVE TONSILLITIS. 

Etiology. — The etiology is almost identical with that of the follicu- 
lar type. Suppurative tonsillitis is most common in adolescence, and 
individual disposition for unknown reasons is an important factor. 

Symptoms. — The early symptoms, local and general, resemble 
those of the follicular type but are often more severe from the onset; 
one, or less often both, tonsils are greatly swollen, tense, cedematous, 
deep red and may show distended lacunae. The pain often radiates to 
the ears. The swollen tonsils may come in contact, or if but one tonsil 
is swollen it may reach over to the sound side. There is often coin- 
cident stomatitis and a free salivary flow. The palate and uvula are 
frequently cedematous and covered with muco-pus. Swallowing 
causes great pain in the throat, the jaw cannot be depressed because 
of the swollen, painful angular glands, and the speech is nasal. The 
toxsemic prostration is often profound, the fever ranges between 103 
and 105 degrees and the pulse between 100 and 140. 



CHRONIC TONSILLITIS 587 

Incision in the first two or three days evacuates no pus and only 
blood and serum escape. In a few days fluctuation is felt in the tonsil, 
or anterior to and above the tonsil (peritonsillar abscess). Introduction 
of a probe into the early and often unsuccessful incision is followed by 
escape of pus and by immediate relief. The abscess may break spon- 
taneously, usually forward and rarely toward the throat, when, in rare 
cases, especially when rupture occurs during sleep, suffocation or 
aspiration pneumonia may follow. In equally rare instances ulceration 
may reach the carotid with sudden and fatal hemorrhage. 

Treatment. — (a) For prevention tonsillectomy by the knife or gal- 
vanic snare is indicated after an individual tendency is manifested. 
(6) In local treatment an ice-bag placed over the neck is beneficial. 
Local applications to the tonsils are at the best uncertain remedies. 
It is good practice, early in the course, to introduce a knife, covered 
with adhesive plaster to within half an inch of its point, above and 
somewhat inside the tonsil; blood and serum escape, tension, oedema 
and pain are relieved and the later abscess more readily points toward 
the cut; the wound is carefully opened with a blunt probe every day; 
early incision is preferable to scarification, (c) Salicylates apparently 
help and possibly hasten maturation. Opium and coal tar products 
relieve the pain to some extent, (d) In exceptional cases, intubation, 
tracheotomy or immediate excision of the tonsil are indicated, because 
of great swelling or collateral oedema, (e) The diet is necessarily liquid. 
(/) In convalescence, iron and strychnine overcome the resulting pros- 
tration and ansemia. 



(C). CHRONIC TONSILLITIS. 

Synonyms. — Chronic inflammation; tonsillar hypertrophy; hyper- 
plasia of the pharyngeal or lingual tonsils; adenoids; aprosexia. 

Etiology. — (a) Repeated acute attacks of tonsillitis cause chronic 
hypertrophy in some cases, and in others the tonsils gradually indurate 
and shrink. (6) Waldeyer's "Schlundring" of lymphadenoid tissue 
consists of the two tonsils, the adenoid tissue in the nasopharyngeal 
vault (Kollicker's pharyngeal tonsil, or "adenoids" in the common 
acceptation), and the so-called lingual tonsil. Variously combined 
hypertrophies of these structures may be noted, occasionally as con- 
genital growths, but most frequently in young children, and sometimes 
in adults. They generally begin during the third or fourth year and may 
develop until puberty. Adenoids are found in 1 per cent, of children 
(Meyer), though other statistics give 3 per cent, or even higher 
figures. Rickets, scrofula, the lymphatic constitution and various acute 
infections involving the throat, as diphtheria, are cited as predisposing 
conditions. 

Symptoms. — 1. Local Changes. — (a) The enlarged tonsil may con- 
tain in its crypts cheesy plugs, which occasion an extreme faior ex 
ore. The plugs may be expressed ; calculi may result from a deposit of 



588 DISEASES OF THE DIGESTIVE TRACT 

lime salts. The pharyngeal mucus is increased, is sometimes tinged 
with blood, and is expectorated with difficulty, (b) Adenoids in the 
nasopharyngeal vault occur alone or with tonsillar hyperplasia. They 
are most often papillomatous, less often sessile; they are reddish, very 
vascular and range up to the size of a bean, (c) Hypertrophy of the 
"lingual tonsil" often disturbs deglutition. Enlarged tonsils and adenoids 
produce most of the following changes by stenosing the posterior nares. 

2. Sequences. — (a) Oral breathing is the earliest symptom, and is 
first noticed during the night, when sleep is disturbed by night terrors 
(pavor nocturnus) and by disordered and sometimes irregular breathing, 
for a time stertorous, and then interrupted. Lying down may occasion 
asthmatic seizures or Balne's paroxysmal cough, (b) After some time 
changes in the mouth are noted. The palatal vault is high from atmos- 
pheric pressure in the mouth, and the transverse measurement between 
the upper teeth is proportionately diminished; there is less room for 
the teeth to erupt, (c) In the nose, the anterior nares are small and 
retracted, and the voice is nasal (rhinolalia claustra); the consonants 
n and m are pronounced with difficulty. Bloch associated oral breath- 
ing with stuttering. The senses of smell and taste are obtunded. 
Hearing is impaired by pressure of adenoids on the Eustachian tubes, 
by inflammation in the tubes or by retraction of the tympana from low 
atmospheric pressure in the nasopharynx, (d) The fades is charac- 
teristic; it is vacuous and apathetic, the nose is pinched, the mouth open 
and the lips swollen. The so-called "adenoid habitus" may be ob- 
served without adenoids, as a stigma of degeneracy, (e) The mentality 
is altered in chronic cases; the cerebral reaction is slow, the memory 
tardy, the disposition sullen and the power of concentration diminished; 
this latter condition was named aprosexia by Guye. Woodward refers 
the physical changes to some toxin (cytotoxin) elaborated in the 
hyperplastic lymphoid tissue. (/) There are other nervous symptoms. 
Headache is common. Adenoids cause some cases of habit-spasm. 
Night terrors have been mentioned. Enuresis nocturna results from 
carbon dioxide operating on the brain during sleep (Schech). (g) 
Development is sometimes retarded, (h) Changes in the contour of the 
thorax were noted by Dupuytren (1828), J. M. Warren (1839) and 
Lambron (1861). The pigeon- or chicken-breast is the most common 
deformity. The sternum juts forward, from which the ribs slant 
sharply backward; at the level of the diaphragm there is a circular 
depression, and inspiratory retraction is caused by the contraction of 
the diaphragm. The funnel breast, marked by a deep depression of 
the lower part of the sternum, is less commonly due to adenoids, and 
like the chicken-breast also results from other causes. The " emphy- 
sema chest " may result from adenoids, (i) Scheir finds that the cervical 
lymph glands are also enlarged and that the blood evidences a decrease 
in haemoglobin, two- to three-fold increase in the white cells, and a 
distinct lymphocytosis. (Plate XI). 

Diagnosis. — The oral breathing, the adenoid facies and mental 
disturbance, palpation of the adenoids in young children and their 



PLATE XL 



FIG. 1. 




FIG. 2. 




Types of the "Adenoid" baeies. (Posey and Wright.) 



(ESOPHAGEAL INFLAMMATION, NECROSIS, ULCERATION 589 

rhinoscopic detection in older ones, and the mere inspection of hyper- 
plastic tonsils determine the diagnosis, In the prognosis of untreated 
cases, the possibility of deafness, mental deficiency, retarded growth, 
asthma, and emphysema should be borne in mind. Colds, acute re- 
current tonsillitis, diphtheria and probably other infections are more 
likely both to develop.and to produce disproportionate symptoms. In 
some few cases the hyperplastic tissues may indurate and atrophy, but 
this spontaneous issue should have no essential influence in their 
management. 

Treatment.— Palliative treatment by astringents is useless. The 
general health should be maintained by out-door life, an ample diet, 
hydrotherapy, and by cod-liver oil, iron and other measures which are 
employed in scrofula and tuberculosis. Hypertrophied tonsils should 
be removed at once by the knife or in several sittings by the galvanic 
cautery, for details of which the reader is referred to special* treatises. 
Adenoids large enough to cause symptoms should always be removed 
early under anaesthesia, by the finger or curette; ether is far less dan- 
gerous than chloroform, which frequently causes death in any disease 
of the lymphadenoid tissues (the status thymicus or lymphoid constitu- 
tion). The sequences above described usually subside soon after 
operation, though oral breathing is a habit somewhat hard to break. 
At night a bandage should be used to keep the mouth closed. 



DISEASES OF THE (ESOPHAGUS. 

(A). INFLAMMATION, NECROSIS, ULCERATION. 

1. Oesophagitis. — This is an uncommon finding at autopsy. Its 
causes are (a) mechanical, as from foreign bodies, strictures or dilata- 
tion of the oesophagus; (b) chemical, as from alcohol, tobacco, corros- 
ive poisons or acid vomitus; (c) thermal; (d) hypostatic, in cardiac or 
pulmonary affections; (e) rarely extension from pharyngeal or laryn- 
geal inflammation; (/) acute infections, as measles, smallpox, scar- 
latina, and diphtheria. Oesophagitis is almost physiological in the 
new-born after the ingestion of the first meals of life. Its pathology in 
general is that of pharyngeal or nasal inflammation; it is marked by 
local or diffuse, acute or chronic redness, swelling and hypersecretion. 
Special pathological forms are follicular catarrh, sometimes resulting in 
follicular ulcers or retention cysts in the submucosa; exfoliative 
oesophagitis (o. dessicans superficialis); the fibrinous form, observed 
in various acute infections, in uraemia and rarely in hysteria; genu- 
ine diphtheria; the pustular eruption of smallpox; the toxic form 
resulting from caustics or acids; the very rare phlegmonous or purulent 



590 DISEASES OF THE DIGESTIVE TRACT 

form (only 12 cases are on record) which occurs as a single bulging 
submucous abscess or as diffuse submucous suppuration and often 
perforates in many places into the oesophagus which then presents a 
sieve-like aspect; forms due to the o'idium albicans, or ray fungus, of 
which primary cases are reported. In chronic cases the epithelium 
may thicken (leukoplakia) or hypertrophy (in papillomatous forms). 

Symptoms. — Symptoms are absent in slight grades of inflammation. 
In marked cases there is pain, which is sometimes continuous and 
substernal, and at other times is elicted by speaking, movement or 
pressure on, or movement of, the spine. Dysphagia is constant in 
marked inflammations. Mucus, blood, pus or eschars, depending on 
the nature and cause of the inflammation, are brought up by gagging 
efforts. Fever is common in the more severe types, in which the local 
symptoms may be wholly subordinate to the causal disease (diphtheria, 
smallpox, etc.). In inflammation due to acids or alkalies, the history, 
local symptoms and eschars in the mouth and pharynx are distinctive. 

Treatment. — Treatment is usually palliative at the best, depend- 
ing on the cause. Narcotics are given for pain, demulcents as acacia 
and ice, ice-cream and a liquid diet for the local irritation, and if these 
cause oesophageal irritation nutrient enemata are given (v. Gastric 
Ulcer). 

2. Necrosis. — This may be due to intense corrosive poisoning; to 
pressure from without, as from struma, aneurysm, foreign bodies, or 
sounds which are left in the oesophagus to dilate strictures; or to decu- 
bitus or "bed sores of the gullet," first described by Dittrich (1850) in 
connection with laryngeal perichondritis, due to pressure of the larynx 
upon the gullet and promoted by fever, inanition and infections. 
(Esophagomalacia is softening of the part by regurgitation into it of the 
gastric acid; it occurs chiefly after death, but some few cases appear 
to develop during the death agony. 

3. Ulceration. — Aside from cancer (v. i.), follicular ulceration, 
caustic ulcers, syphilis and tuberculosis, there is the peptic or round 
ulcer. Peptic ulcer was first described by Cruveilhier, who correctly 
identified it with round ulcer of the stomach. Twenty-three cases are 
recorded in the literature. It appears in four main conditions (a) by 
extension from the round ulcer of the cardiac orifice, (6) in ulcers at the 
pylorus or duodenum, which produce gastric dilatation, (c) in multiple 
hemorrhagic infiltrations of the oesophagus, stomach and duodenum 
and (d) in alcoholism, arteriosclerosis and other as yet imperfectly 
investigated conditions. Its chief symptom is dysphagia; its pathology 
and complications, as hemorrhage, perforation and stenosis, as well as 
its treatment, are practically identical with those of gastric ulcer, with 
which it is often associated. 

(B). STENOSIS OR STRICTURE OF THE (ESOPHAGUS. 

Stenosis is the most important and frequent of oesophageal diseases. 
In this connection von Mikulicz's conclusion is important, viz. that 



(ESOPHAGEAL STENOSIS OR STRICTURE 591 

the oesophagus is a closed tube only in its cervical segment and that its 
cardiac orifice is not physiologically closed. 

Etiology. — (a) Interstitial factors, i. e., in the wall of the oesophagus, 
are the most important; cancer (v. i.) causes 90 per cent, of all stenoses 
(v. Leyden, Kraus, Rosenbach); stenosis from ulceration by caustics 
and acids comes next ; then comes stenosis by diverticula or pouches^, i.) 
which, bulging out of and beside the oesophagus, exert upon it a lateral 
compression ; other rarer ulcerative stenoses result from healing gum- 
mata, tuberculous lesions, smallpox and other suppurative affections, 
and from peptic and diphtheritic ulcers; muscular spasm causes a few 
cases; congenital stenosis or atresia is very rare (15 cases recorded) 
and occurs chiefly as a cut de sac, incomplete development or fistulous 
communications with the trachea or brouchi. (b) Extra-cesophageal 
factors, compressing the tube from without, are next in importance and 
include aortic aneurysm or abnormal branches from the aorta; verte- 
bral lesions, (tumor, cold abscess, exostosis, great deformation); 
anthracotic lymphadenitis and malignant lymphoma; thyroid or 
thymic inflammation or hypertrophy; mediastinitis callosa, pericarditis 
effusiva, pulmonary neoplasms, and luxation of the hyoid bone or 
clavicle, (c) Intra-cesophageal factors comprise the fewest causal 
agents, as foreign bodies, pedunculated polyps which usually form from 
the lower pharynx, and O'idium albicans. 

Apart from the special pathology of these causes, stenosis occur chiefly 
(a) at the lower third of the oesophagus, (b) near the level of the bifurca- 
tion of the trachea, or (<?) high up in the oesophagus. The stenosis is 
more often single than multiple and more often annular than longi- 
tudinal; it varies from slight stenosis to complete atresia, in which the 
tube may be seen as an impervious cord. Above the stenosis the tube 
is dilated and its musculature is usually vicariously hypertrophied in 
order to force food through the narrowed point. 

Symptoms. — Symptoms vary with the cause and its extent; thus 
mechanical dysphagia may be quite secondary to aortic aneurysm and 
may vary from time to time with the pressure exerted upon it; in the 
cicatrizing ulcers dysphagia is the only symptom. When stenosis is 
advanced, the food and later the fluids taken, regurgitate after a short 
time, if the stenosis is low, or at once if the stenosis lies just below the 
pharynx; as a rule, the subjective localization described by the patient 
is unreliable. The regurgitated food is neutral, macerated, fermented, 
and often contains round cells, mucus, or blood, but never HC1 nor 
pepsin. (Esophageal pain is common, but its occurrence depends on 
the causal lesion. Singultus is rather frequent when the lesion lies near 
the diaphragm. Dyspnoea may result from pressure upon the air 
passages by the dilated portion of the oesophagus above the stricture. 

Physical Examination and Diagnosis.— The chest should be 
examined for aneurysm, retrosternal struma, and lung tumors, and the 
finger should be introduced as far as possible down the throat, to 
exclude the possibility of lesions situated high up in the oesophagus or 
larynx. Illumination of the oesophagus (&sophagoscopy) may give 



592 DISEASES OF THE DIGESTIVE TRACT 

excellent results if done by an expert, but its general application is very 
limited. Local signs are elicited chiefly in three ways — by sounding, 
by auscultation and by the arrays. 

1. Sounding. — A soft sound is far less dangerous than a hard one, at 
least for the first examination and does the least damage in cases of acute 
oesophagitis, aneurysmal compression, and ulcerating cancer. It is 
not sufficient to pass one stricture, as there may .be others lower down, 
whence the sound should be passed into the stomach. The length of 
the oesophagus is 10 inches or 25 cm. (or 15 per cent, of the patient's 
height); from the upper incisor teeth to the oesophagus 6 inches or 
15 cm., from the teeth to the cardia 16 inches or 40 cm. Recently it 
is maintained that the last measurement should be 19.7 inches, or 
50 cm. The length of the cervical portion is 2 inches or 5 cm., of 
the thoracic 6| inches or 17 cm., and of the abdominal part 1J inches 
or 3 cm. From the teeth to the level of the tracheal bifurcation is 9 
inches or 23 cm. 

2. Auscultation. — Deglutition is marked, physiologically, by two 
murmurs, which can be heard with the stethoscope six to eight seconds 
after the beginning of the act, first a short murmur and then a longer 
one. In cases of marked stenosis the swallowing sound is heard at a 
point just above the lesion; this is a valuable help when aneurysm is 
suspected and sounding is therefore feared. In the cervical part of the 
oesophagus the noise results chiefly from the movements of the phar- 
ynx; in the thoracic segment the stenotic murmur is heard to the left 
of the spine from the first to the ninth dorsal vertebra. Stenosis near 
the tracheal bifurcation often gives a delayed first murmur, and a 
gurgling, spurting character in both murmurs; in the lowest segment 
the murmurs are heard just above the cardia, at the ninth or tenth 
dorsal vertebra. 

3. X-rays. — The arrays may show the outline of the dilatation above 
the stricture (v. i. Dilatation of (Esophagus). 

Prognosis. — The prognosis depends on the cause. Cancerous 
stricture may ulcerate, thus relieving the local symptoms, though the 
cachexia increases. Strictures resulting from caustics often improve. 
In cases where the cause cannot be relieved, the same symptoms result 
as in oesophageal cancer (q. v.). Perforation into the lungs, pleura, or 
air passages, or into the mediastinum or vessels, may follow. Aspira- 
tion pneumonia, which is often gangrenous, is not infrequent. 

Treatment. — The remediable etiological factors are few, except 
that iodides may be given in syphilis or aneurysm. Foreign bodies may 
sometimes be removed by a long forceps, though of course with the 
direction of the cesophagoscope. In cancerous and aneurysmal 
strictures, probing and dilatation are dangerous. Dilatation by sounds 
is attended by the risk of perforating the oesophagus. Sounds should be 
introduced beside the index finger, and the patient's head should be 
thrown slightly backward; severe gagging may be overcome by 
painting the pharynx with cocaine, though it is often as much psychical 
as oesophageal, and assurance is a better preventive than drugs. The 



(ESOPHAGEAL DILATATION. DIVERTICULUM 593 

subject should first swallow some olive oil to facilitate passage of the 
sound. In passing the sound it should be held like a pen and pushed 
with exceeding gentleness. Trousseau's tapering ivory olive points are 
excellent, but care is necessary, and successively larger sizes should be 
used. Sounds may be left in the oesophagus for some minutes or an 
hour, or even permanently, but pressure necrosis may then result. 
It is at times necessary to introduce filiform bougies, such as are used 
in passing very narrow urethral strictures. Silver balls (2 to 7 mm. in 
diameter) with threads attached, may be swallowed; they should be 
carefully pulled out after remaining in over night. When the obstruc- 
tion is high, external rather than internal cesophagotomy is advisable, 
though oesophageal surgery is still in its infancy. As first practiced by 
von Bergmann, after opening the stomach, dilatation may be employed 
from below. Impermeable strictures call for gastrostomy and rectal 
alimentation. See Treatment of Intestinal Obstruction for 
thiosinamin. 

(C). DILATATION. DIVERTICULUM. 

Etiology. — Dilatation involves the entire circumference; diverticulum 
involves but part of it. Secondary dilatation may occur above stenosis 
of the oesophagus or above the cardiac end of the stomach. It seldom 
extends more than an inch and a half (4 cm.) above the stricture; it 
rarely follows pyloric stenosis. Primary (idiopathic) dilatation may 
be local or total. Marked . dilatation above the cardia, Luschka's so- 
called "fore-stomach" is an example of the local form, which is usually 
congenital. The diffuse idiopathic dilatation results without any causal 
organic stenosis and is seen chiefly between the years of twenty and 
forty. Its actual cause is disputed. Most clinicians incline to the view 
advanced in 1888 by Meltzer, of New York, that its cause is a cardio- 
spasm due to abolition of cerebral inhibition on the cardia; in fact 
Kraus reports a case with great atrophy of both vagi; Rosenheim 
maintains that atony and ectasia are primary and cardiospasm second- 
ary. The role of trauma, acute oesophagitis and congenital weakness 
of the oesophageal musculature is uncertain. Cardiospasm pro- 
duces a great hypertrophy of the cardiac muscle, even six times its 
normal thickness, and diffuse total dilatation so that the oesophagus 
may measure 18 inches (46 cm.) instead of 10 inches (25 cm.) in length 
or 12 inches (30 cm.) in circumference (Luschka). Though Zenker 
collected but 18 cases in 1878, the number is increasing; nearly a dozen 
were reported in 1904 (Sippy, Tyson, Kinnicutt, and Sossen), and up to 
1905 over 90 are recorded. The mucosa is catarrhal, thickened, or 
eroded, and the muscularis is hypertrophied or fatty. 

Symptoms. — The symptoms are gradual or sudden in onset. There 
is dysphagia, which may often be overcome by effort; the patient feels 
that the food does not reach the stomach. Regurgitation of the food, 
especially the portion last swallowed, usually occurs soon after eating 
or when the patient lies down; it may measure a quart, is neutral, 

38 



594 DISEASES OF THE DIGESTIVE TRACT 

decomposed if it has been retained for some time, and contains lactic 
and butyric acids but no hydrochloric acid, pepsin or rennet. The 
regurgitated food may again be swallowed (rumination). Vomiting of 
course is impossible. The pressure of the stagnant food or fluid in the 
gullet may produce vagus symptoms, such as dyspnoea or palpitation. 
The sound, when introduced, moves freely from side to side, but meets 
at least temporary resistance at the cardia, though pressure usually 
overcomes the obstructing cardiospasm. One sound, introduced into 
the stomach, may recover HC1, pepsin, etc., but another, introduced 
to but not beyond the cardia, recovers fluid or food with a neutral re- 
action; methylene blue solution poured through the first tube returns 
blue; that recovered by the second tube is colorless. Distention of the 
oesophagus with carbon dioxide gives tympany, or with water dulness, 
near the left of the sixth to the ninth dorsal vertebrae, sometimes above 
the left costal arch, or even in the epigastrium. The oesophagoscope 
may reveal the dilatation; a distinct shadow may often, though not 
always, be seen by using the a>rays after the patient has eaten potatoes 
or bread which have been well mixed with bismuth. The second 
swallowing bruit may be absent or altered, or sometimes sounds like 
fluid running into fluid. Marasmus and constipation and often death 
result, but the clinical course may cover years or decades. 

Treatment. — Treatment is rather unsatisfactory. Internal galvan- 
ization or faradization has been recommended. Olive oil gss, before 
meals may help the fluid (or the sound) to pass the cardia. Continued 
use of the stomach tube may be effective, but in some instances causes 
oesophagitis; its life-long use is often required. Lockwood's pneu- 
matic bag may be introduced empty on a sound into the stomach, then 
inflated and withdrawn slowly and gently through the cardia ; Strauss 
praises this method. Gastrostomy and rectal feeding may be indi- 
cated. Operation should not be delayed too long. The cardia has 
been operated upon a number of times. Mikulicz operated six times — 
with five cures — by entering the stomach, forcibly distending the cardia 
and rupturing its fibers submucously. 

Diverticulum. — This involves only an arc of the oesophageal circum- 
ference. Two types are distinguished: 1. Zenker's pressure diver- 
ticulum (pulsion-diverticulum) of which Rosenthal (1902) could collect 
but 180 cases. It is found chiefly in men (77 per cent.), and is a pouch 
which forms very gradually on the posterior oesophageal wall, usually 
near the junction of the pharynx and oesophagus, and nearly always 
consists of only the mucosa and submucosa, — a kind of pyriform or 
bottle-shaped oesophageal hernia. Its onset is very gradual, for the 
muscle, which is probably congenitally weak, yields before intra-oesoph- 
ageal pressure, trauma, foreign bodies, and the stagnating food. The 
early symptoms are signs of pharyngo-cesophagitis, hawking and 
dysphagia, and food entering the sac rather than the oesophagus; the 
axis of the sac, which dips between the gullet and the spine, is roughly 
parallel with that of the oesophagus; many of its symptoms are those 
of a high oesophageal stenosis. The food stagnates and regurgitates 



CANCER OF THE (ESOPHAGUS 595 

with a foetid odor. In 33 per cent, of cases a tumor appears in the 
supraclavicular region, which is dull when filled with food or tym- 
panitic when distended with carbon dioxide; it sometimes can be 
smoothed out, but this makes the food regurgitate. The murmurs on 
swallowing are protracted (in 50 per cent.). A sound, if introduced, 
usually enters the sac, and another, if slightly bent, enters the gullet; 
this also differentiates the diverticulum lower in the gullet, which is 
even less common. Examination by the oesophagoscope is generally 
negative, but the arrays may show a characteristic shadow. There may 
be pressure on the heart, trachea, vagus, recurrent laryngeal nerve, and 
brachial plexus. The clinical course is usually protracted, even to 
twenty or forty-nine years, and the spontaneous evolution is inanition 
in over 50 per cent, of the cases, gangrene (15 per cent.) or perforation 
with cervical phlegmon. Treatment includes feeding by means of the 
sound, rectal nutrition, gastrostomy, and surgical resection; this was 
first performed by von Bergmann (1890), 24 cases being recorded with 
20 per cent, mortality. Diverticula low in the oesophagus can only be 
treated by long-continued sounding. 

2. Rokitansky's traction-diverticulum is frequent; according to 
Riebold it is found in 3.5 per cent, of all autopsies. It is due to extra- 
cesophageal traction, which draws a small part of the gullet out into a 
funnel-like form. Over 80 per cent, is due to indurative periadenitis 
around caseous or anthracotic lymph glands. Cicatricial mediastinitis 
from pleuritis, pericarditis or vertebral disease may produce the same 
effects. It usually, therefore, occurs at the level of the tracheal bifur- 
cation. Diverticula may result from both traction and pressure. 
Traction-diverticulum begins early in life, is usually single, is less 
marked on the anterior or lateral wall, barely exceeds five to ten mm. 
in depth and is rarely discovered during life, though some have been 
seen with the oesophagoscope. Its chief danger is ulceration at its apex 
and perforation into the trachea, bronchi, vessels, pericardium, pleura?, 
or mediastinum, with resulting gangrene of the lungs, fatal hemorrhage, 
pneumothorax or phlegmonous mediastinitis. There is no treatment. 



(D). CANCER OF THE (ESOPHAGUS. 

Etiology. — Its frequency is rated at J to 1 per cent, of autopsies, and 
it is said by Petersen-Borstell to rank third among cancers (stomach 
33 per cent., uterus 15 per cent, and oesophagus 6 per cent.). Its etiology 
is unknown, (a) Scars, trauma, ulceration and traction diverticulum 
are promoting causes; (6) 75 per cent, occurs in males, and 80 per 
cent, between the fortieth and sixtieth years; 8 per cent, occurs before 
the fortieth year; Stewart records a case aged twenty-three, and Hei- 
mann one aged nineteen. 

Pathology. — Cancer of the oesophagus is almost always single and 
primary, though cancer of the stomach, pharynx or mediastinum may 
rarely involve the oesophagus secondarily. Most cases are squamous 



596 DISEASES OF THE DIGESTIVE TRACT 

epithelioma, arising from its pavement epithelium; scirrhus, colloid 
and medullary forms are rare. Localization; most cases (57 per cent.) 
develop in the lowest third of the oesophagus; many (33 per cent.) in 
the middle, and the least (10 per cent.) in the upper third; its favorite 
sites are near the cardia, at the tracheal bifurcation level and just back 
of the cricoid cartilage. The muscularis sometimes hypertrophies above 
the cancer, where some dilatation may occur, but not very frequently. 

Symptoms. — The onset is usually insidious. Signs of oesophagus 
stenosis (v. s.) develop in varying grades; stenosis generally advances 
slowly but is occasionally sudden. It may lessen as the cancer ulcer- 
ates. Its symptoms are those of stenosis, as dysphagia, rather indefi- 
nitely located pain, regurgitation of food and perhaps also of bloody 
mucus or of necrotic cancer tissue. Its signs are also identical, as 
obstruction on sounding, alteration of the murmurs, sometimes the 
detection by the cesophagoscope of a papillomatous or ulcerated neo- 
plasm, and quite rarely tumor particles found in the fenestra? of the tube. 
Cachexia develops; constipation, indicanuria and peptonuria are 
usual; acetonuria is fairly frequent. Extension, by contiguity, occurs 
to the spine, mediastinum, and cardia, or in 60 per cent, of cases by 
metastasis ; the mediastinal and peribronchial lymph nodes are usually 
invaded, the supraclavicular often and the upper cervical seldom. 

Complications. — There may be pressure on the recurrent laryngeal 
(13 per cent.), vagus or mediastinal veins and arteries, on the sym- 
pathetic ganglia (13 per cent.) or brachial plexus. Perforation occurs 
in over 50 per cent., most often into the larger air passages, when aspir- 
ation pneumonia or gangrene may follow ; into the lung, pleura (ichor- 
ous pleurisy or pneumothorax resulting) ; into the aorta (fatal hemor- 
rhage), heart, pericardium, and mediastinum. Pyaemia, pulmonary 
tuberculosis, and marantic thrombosis, occur in some cases. Death 
is the inevitable outcome, usually within thirteen months ; it occurs with 
emaciation, subnormal temperature, small slow pulse, slow shallow 
breathing, flattened abdomen, and perhaps intoxication symptoms, as 
coma and fever. 

Diagnosis. — The diagnosis is based (a) on the fact that there is a 
stricture of the oesophagus, which in 90 per cent, of all cases is car- 
cinomatous; (b) on evidences of neoplasm, as age, cachexia, cancerous 
nodes, metastases, and perhaps tumor particles on the sound, (c) 
Other tumors, as lipoma, myxoma, myoma (11 cases, Bryant, 1906), 
fibroma, or sarcoma, are of greater pathological than clinical import- 
ance, except accessible fibropapillomata of the upper gullet or lower 
pharynx. 

Treatment. — The treatment is that of stricture or stenosis; nourish- 
ing enemata, feeding by the stomach tube, gastrostomy and for pain, 
narcotics are indicated. (Esophagectomy is seldom necessary, as 
less than 10 per cent, of these tumors occur in the cervical portion, 
accessible to surgical interference. Most of the operated cases die. As 
to gastrostomy, Schmidt in 1897 reviewed 236 cases, in which 45 per 



PERFORATION, RUPTURE, HEMORRHAGE OF THE (ESOPHAGUS 597 

cent, did not live longer than a week, and nearly 90 per cent, not more 
than one hundred days. 



(E). PERFORATION; RUPTURE; HEMORRHAGE OF THE 
(ESOPHAGUS. 

1. Perforation may result from causes within or without the 
oesophagus. Internal causes include ulcers, foreign bodies, diverticula, 
cancer, and use of the sound ; external causes are aneurysm, gravitating 
abscess, lung cavities or gangrene, suppurating lymph glands or 
trauma. It is marked clinically by mediastinitis and cervical cellulitis, 
which is usually phlegmonous. (Esophageal fistulse may communicate 
with the air passages, from which fluid or food are seen by the laryngeal 
mirror to be expectorated; a communicating tuberculous cavity may 
become flat when the patient drinks or eats, and the flatness is changed 
to tympany when the food or drink is expectorated; this is well tested 
by giving the patient milk, which will be brought up from the larynx. 
Aspiration gangrene, pneumopericardium, pneumothorax, and fatal 
hemorrhage are quite common causes of death. 

2. Spontaneous rupture (so-called) is a very rare affection, there 
being only twenty-five certain cases on record. It is often confused 
with cesophagomalacia, in which the rupture is not longitudinal nor 
clean-cut as in genuine rupture. The first case, and one of the clearest, 
was reported by Boerhave (1714). It follows over-eating or severe 
vomiting, and most victims have been alcoholics. There is great and 
sudden pain over the lower oesophagus (where most ruptures occur) 
and over the xiphoid, severe vomiting, haematemesis, collapse, and 
subcutaneous emphysema. Death is the rule from collapse, phlegmon- 
ous or ichorous mediastinitis, pleuritis, or pneumothorax. Treatment 
is wholly expectant. 

3. Hemorrhage may follow all varieties of oesophageal ulceration, 
external or internal trauma, toxic oesophagitis, softening, and aneurys- 
mal or other perforations. Varicose veins in the lower oesophagus, 
first described by Le Derberden (1837), are most often complica- 
tions of liver cirrhosis, less often of syphilis, senile atrophy, and pyle- 
thrombosis. The diagnosis and localization of the bleeding point is 
at best only suggested by the history and previous physical findings. 
Treatment consists chiefly of keeping the patient absolutely quiet, of 
giving morphine, and of rectal feeding, as in gastric hemorrhage. 



(F). MOTOR AND SENSORY DISTURBANCES OF THE (ESOPHAGUS. 

These will be considered under Affections of the Vagus (q. v., 
under Nervous Diseases). 



598 DISEASES OF THE DIGESTIVE TRACT 

DISEASES OF THE STOMACH. 

(A). ACUTE GASTRITIS (ACUTE CATARRH, ACUTE DYSPEPSIA). 

Acute gastritis is a better term than catarrh, which implies a super- 
ficial inflammation of the mucosa. Simple gastritis will be first con- 
sidered. 

I. Simple Gastritis. 

Etiology. — It is a very common primary and secondary affection, 
(a) Its most important mechanical cause is improper food or improper 
eating; rich food, an excessive amount, partial mastication, washing 
down the food with water, hurried eating, eating when very hungry, 
idiosyncrasies to certain kinds of food, decomposed articles containing 
bacteria (B. coli) or ptomaines (tainting of food is most common in hot 
weather), and excessive ingestion of cold water and fruit are accessory 
factors, (b) Thermal factors include too hot or too cold foods, 
especially when taken on an empty stomach, (c) Chemical causes; 
aside from acids and caustics (see Toxic Gastritis), alcohol ranks fore- 
most; autotoxins may excite acute gastritis, as those of acute or 
chronic nephritis, cholsemia, or gout, (d) Some cases are clearly in- 
fectious; the condition may occur in variola, measles, typhoid, grippe, 
and pneumonia, as a secondary manifestation, or occasionally as an 
independent febrile affection ; this happened in the Christiana epidemic 
reported by Hausemann (1880), in which 6,000 persons were affected 
within three weeks, (e) Certain conditions are somewhat predisposing 
to acute gastritis; for example, stasis (from diseases of the heart, lung, 
or liver), tuberculosis, cancer, syphilis, chlorosis, diabetes, leuksemia, or 
affections of the higher alimentary mucosa. In some cases a familial or 
even hereditary tendency is noted, known as "the delicate stomach" 
by the laity. Nervous factors, as anger or excitement, are sometimes 
apparently causative, though they may be confused with the digestive 
neuroses. 

Symptoms. — 1. Digestive Symptoms. — These are sometimes absent, 
as was demonstrated by Beaumont in the celebrated St. Martin case 
of gastric fistula. The appetite is usually lost or perverted. The tongue 
is thickly coated with white fur and rather dry mucus. The mouth is 
dry and there is a disagreeable taste, great thirst, even though the 
salivary flow is often increased. Hiccough, eructations, a sense of 
gastric distention, pressure, or pain and tenderness over the stomach, 
are common. Nausea and vomiting characterize the more marked 
cases; the vomitus is pale yellow, bitter, and contains little or no hydro- 
chloric acid, though lactic, butyric and fatty acids are common; there 
is much mucus, which is frequently flecked with blood. Corresponding 
anatomical changes are found, though few uncomplicated cases come 



SIMPLE GASTRITIS 599 

to autopsy; the mucosa, particularly near the pylorus, is red, swollen, 
smeared with adherent mucus, sometimes slightly eroded or dotted with 
punctate ecchymoses; the dilated racemous vessels, as seen by the 
gastroscope, or through a gastric fistula, are less conspicuous at autopsy 
for the blood in great part leaves the organ after death ; microscopically 
the salient findings are leukocyte emigration and granular degeneration 
and swelling of the mucous and other glandular cells. 

2. General and Other Symptoms. — Herpes is an occasional finding. 
Constipation is the rule, though diarrhoea or icterus sometimes occurs 
in gastro-enteritis. The urine is scanty because of the vomiting; it 
deposits a lateritious sediment and sometimes contains indican or 
acetone. Nervous symptoms — as frontal headache, vertigo, intercostal 
neuralgia, and depression — are common, but convulsions (acetonemia) 
and other marked nervous manifestations occur infrequently in young 
and sensitive individuals. Fever is quite uncommon; when present, 
it is usually irregular and ephemeral. 

Diagnosis. — The diagnosis is not difficult when the course is short 
and afebrile, as is usually the case. With fever or some constitutional 
symptoms it is an excellent practice to regard the acute gastritis as a 
symptom, until, at least, typhoid, exanthematous disease, or nephritis 
can be excluded by the later clinical evolution. Confusion is possible 
with a tabetic crisis or with the vomiting of pregnancy and hysteria. 

Treatment. — (a) Prophylaxis embraces the etiological factors. 
(b) Complete rest of the stomach for one or more days is the first active 
indication; no rectal feeding is required for twenty-four to forty-eight 
hours, by which time the gastric equilibrium is in great part restored; 
warm water may be given by rectum to unload the bowels and to allay 
thirst, (c) If gastric irritation persists, the stomach should be thor- 
oughly washed out by the stomach tube, using warm water with a spoon- 
ful of sodium bicarbonate to the quart. Gastric lavage is a better 
measure than the use of calomel or salines, which may irritate the 
inflamed, perhaps eroded mucosa. For the same reason emetics (apo- 
morphine hypodermics, or ipecac by mouth) are to be avoided. Epi- 
gastric fomentations alleviate pain. Obstinate irritation and vomiting 
usually respond to Bartholow's prescription, modified as follows: 

Ac. carbolici gr. iv. 

Ac. hydrocyanici dil 3ss. 

Bismuthi subnitratis 

Sodii bromidi 

Cerii oxalatis aa oiss. 

Mucilaginis acaciae q.s. 

Aquae menthae piperitae q.s. ad §ij- 

M. et S. — One teaspoonful without dilution every half to one hour for six to 
ten doses. 

Opiates give immediate relief, but secondary nausea is an insuper- 
able obstacle to their use. (d) In convalescence, dilute hydrochloric 
acid tt# v to xv and bitters are given after meals, to stimulate and supple- 
ment the gastric secretion. The diet should be simple, moderate in 
bulk and the food should be thoroughly chewed. 



600 DISEASES OF THE DIGESTIVE TRACT 



II. Gastritis Toxica (Venemata). 

Etiology and Pathology. — Acute toxic gastritis is caused by various 
alkalies, acids, and metallic poisons. Sulphuric acid produces a gray 
eschar, nitric acid a yellow one, alkalies a brown, copper a greenish 
blue, silver a deep black eschar, and phosphorus produces an opaque 
milky stain. The pathological changes are usually severe, particularly 
in places with which the corrosives remain longest in contact, as the 
pylorus and posterior wall; these changes range between simple 
epithelial desquamation and catarrh, to hemorrhagic infiltration, 
diphtheroid patches, suppuration, and ulceration. 

Symptoms. — The symptoms are those of gastritis simplex, but more 
severe; pain is intense in the mouth, throat, oesophagus, and stomach, 
and is not relieved by the repeated vomiting. The vomitus is often 
bloody, the epigastrium tender, and the abdomen tympanitic. 

Prognosis. — The outcome varies; (a) collapse after a few hours to a 
day or so is frequent, with small pulse, shallow breathing, subnormal 
temperature, bloody albuminous urine, and other symptoms which 
vary with the poison ingested, (b) The stomach symptoms may 
subside, and death may occur later from blood or visceral changes, (c) 
Strictures may develop, or (d) there may be atrophy of the secretory 
glands (achylia gastrica). 



III. Phlegmonous Gastritis. 

Etiology. — This is a rare form, of which 85 cases are recorded (1903). 
It is an acute suppurative inflammation of the stomach, usually caused 
by the streptococcus ; it begins in the submucosa and infiltrates the other 
coats diffusely or forms a circumscribed mural abscess. It may be a 
primary affection (only 20 are recorded, 1905), but most often occurs 
secondarily (75 per cent.) in sepsis, the acute infections, anthrax, or in 
local diseases as gastric cancer. The writer has seen only one case, 
which followed erysipelas. Eighty-five per cent, occur in adult males. 
Alcoholism and traumatism are predisposing factors. 

Symptoms. — The symptoms are gastric and septic. Besides the 
symptoms of acute gastritis, the vomitus sometimes contains pus, the 
epigastric pain is intense, meteorism is well marked, and there are many 
symptoms of peritonitis, which is a most common complication. In a 
few cases an epigastric tumor marks the circumscribed variety. Sepsis, 
usually in a severe form, causes the high fever (103-5 degrees), the 
pronounced status typhosus, the small pulse, occasional icterus, and 
petechise. 

Diagnosis and Treatment. — A diagnosis is almost impossible, the 
outcome is generally fatal during the second week, and the treatment is 
symptomatic, viz., rectal nutrition and stimulation, narcotics for pain 
and vomiting, and hydrotherapy for fever. Some cases apparently heal 



DIPHTHERITIC, PARASITIC AND CHRONIC GASTRITIS 601 

by rupture into the stomach with cicatrization, and, if the affection is 
suspected, the advisability of operation can be considered. 



IV. Diphtheritic Gastritis. 

This form is due to the Bacillus diphtheria?, and is very rare. Diph- 
theroid gastritis, caused by streptococcic and other infections, is more 
common; it may develop after gastritis toxica, smallpox, pneumonia 
and kindred maladies. 



V. Parasitic Gastritis. 

This form is, in rare instances, due to the Oi'dium albicans, favus 
parasite (Kundrat), anthrax bacilli, larvse of insects and tinese. 

(B). CHRONIC GASTRITIS. 

Chronic gastritis (dyspepsia, catarrh) is characterized pathologi- 
cally by degeneration of the parenchymatous and infiltration of the 
interstitial tissue, and clinically by mucus formation and decreased 
secretion. 

Etiology. — (a) The factors are the same as in acute gastritis, from 
repeated attacks of which chronic inflammation may result. Abuse of 
drugs, especially cathartics, is an important factor. Alcoholism and 
improper eating are most important. Eating hurriedly or at irregular 
hours, inadequate mastication, washing down the food with much fluid, 
excessive use of coffee, tea, ice water, carbohydrates, pastries, or fried 
foods, are salient factors. The chewing of tobacco and to a lesser 
degree smoking may cause chronic gastritis ; stomatitis, carious teeth, 
and pyorrhoea alveolaris, are important causes. Most cases occur in 
adult males, (b) It often accompanies other gastric diseases, as cancer 
or ectasia, (c) It is frequent in tuberculosis, in the ansemias as chlo- 
rosis or pernicious anaemia, and in nephritis, gout, diabetes, syphilis, 
amyloidosis, and Addison's disease. 

The acid form (see Symptoms) of chronic gastritis is usually caused 
by excesses in eating, drinking, and smoking; the subacid form, by the 
abuse of spirits. 

Pathology. — The pathological changes are observed chiefly in the 
pyloric region. The vessels are dilated, imparting a reddish-brown 
color, which in the later stages changes to gray. The mucosa is swollen, 
lax, and covered with tenacious mucus. Sometimes punctate hemor- 
rhages or erosions are observed. In a few cases the mucosa is rough, 
even papillomatous (gastritis polyposa, etat mamellone) . The mus- 
cularis is not essentially changed, as a rule, but is sometimes hyper- 
trophied near the pylorus, or it may be atrophied. Histologically, the 



602 DISEASES OF THE DIGESTIVE TRACT 

glandular cells are granular and fatty, or show a mucoid degeneration 
which extends from the surface toward the deeper layers ; the parietal 
cells cannot be distinguished from the principal cells, the glands are 
often large, sacculated, or cystic, and the tubules show irregular rami- 
fications; eventually the glandular structures may completely atrophy 
(see next sub-heading, Achylia, Atrophy). The interstitial tissue 
shows leukocytic infiltration. 

Symptoms. — The symptoms resemble those of acute gastritis, but 
begin more insidiously and endure longer. 

1. Oral Symptoms. — The tongue is generally, but not always, coated 
with moist white fur, reddish at its tips and indented on its edges; 
these conditions may also result from alcoholic or nicotine stomatitis. 
There is frequently a bitter, sour, salty taste in the mouth, and some- 
times a marked factor ex ore. Increase in the saliva results chiefly from 
the coincident stomatitis. 

2. Gastric Symptoms. — (a) Gastric pain sometimes results from 
spasm of the gastric musculature but is less frequent than is a sense of 
distention or pressure after eating. Soup and fluids (unless they are 
cold) generally cause no distress; coarse or hard foods, as beefsteak, 
hard bread, smoked meat, cabbage, hard-boiled eggs, or cheese, do 
cause distress. (In functional dyspepsia, any kind of food, hard or soft, 
may cause distress) . In some cases of gastritis there is distress when the 
stomach is empty. There may be some tenderness, but it is much less 
than in cancer or ulcer and responds readily to treatment, (b) Belch- 
ing of gas is common; eructations may be odorless, or may contain 
fatty acids and even inflammable gas. Eructations of hydrochloric acid 
are rare, (c) Nausea is more frequent than is vomiting, which may 
result from other coincident conditions, notably from chronic pharyn- 
gitis. The vomitus shows the same findings as the test meal (see Gas- 
tric Chemism). In alcoholics morning vomiting is common (vomitus 
matutinus potatorum), chiefly of saliva swallowed during the night, and 
of mucus. 

3. Gastric Chemism. — Our intimate knowledge of the chemical 
changes in the stomach dates from the introduction of the stomach tube 
by Leube, and the vast amount of work done by many workers, 
especially Riegel, Ewald, and Boas. After washing out the stomach, 
the Ewald test breakfast is given, consisting of a piece of dry bread and 
a cup of weak tea without sugar or cream. In an hour the stomach tube 
is again introduced and the gastric contents withdrawn by expression 
(the patient compressing the abdomen and straining), or by Ewald's 
aspiration bag, similar to Politzer's ear bag; it is seldom necessary to 
pour in any water unless some condition obtains in which the hydro- 
chloric acid is much decreased. Innumerable errors result from con- 
fidence in a single examination and assigning undue importance to the 
gastric chemism alone. It is best to examine the contents chemically 
without filtration. 

(a) The gross examination of the stomach contents shows coarse 
particles of food when the hydrochloric acid is absent or greatly reduced, 



CHRONIC GASTRITIS 603 

or fine subdivision when it is present in fair amounts. A rancid odor 
denotes fatty acids, and a foaming appearance is caused by fermen- 
tation. Mucus is seen in practically all cases, and most clinicians do 
not recognize a simple gastritis without mucus formation, though 
Ewald distinguishes (i) simple gastritis in which the acid and ferments 
are decreased; (ii) a mucous gastritis, in which the acid is greatly de- 
creased, the ferments are present, and there is much mucus; and (hi) an 
atrophic gastritis which will be considered separately. Mucus usually 
indicates a reduction in the hydrochloric acid. Normally there is little 
or no gastric mucus, though there is rather more with an amylaceous 
than with a proteid diet. Mucus of gastric origin is intimately mixed 
with the food and is not yellow, nummular, pigmented, or mixed with 
cells, as occurs when the mucus comes from the mouth or respiratory 
tract. 

(b) The HCl is reduced. It is recognized by the Gunzburg test 
(2 gm. phloroglucin and 1 gm. vanillin dissolved in 30 c. c. of absolute 
alcohol) ; a few drops of the solution are added to an equal amount of 
the filtered gastric contents and slightly heated, without boiling, in a 
porcelain dish, when a carmine-red color develops, indicating free 
hydrochloric acid even in dilution of 1 to 20,000 parts, and not reacting 
to lactic or butyric acids ; the solution should be kept in a dark bottle, 
for it degenerates in the sunlight. The solution should not be kept over 
two months. Boas recommends the following test, which gives the 
same reaction as Gunzburg's test and is less expensive: resorcin 0.5, 
sugar 0.3, dilute alcohol q. s. ad 10.0 gram. HCl exists in a combined 
form or as free acid, which latter probably serves as an antiseptic. 

To find the total free HCl, one of three simple methods may be 
employed, (a) Filter paper is saturated with a 0.5 per cent, alcoholic 
solution of dimethylamidoazobenzol, and dried; HCl colors this 
solution a cherry-red color; when the reaction is obtained on the paper 
with the gastric contents diluted three to six times, about the normal 
percentage of HCl is present; if obtained with less than three dilu- 
tions, subacidity (hypochlorhydria) exists; if with more than six 
dilutions there is hyperacidity (hyperchlorhydria). (6) To 10 c.c. of 
the gastric contents, 25 to 30 c. c. of Gunzburg's reagent is added, and 
then, little by little, the decinormal soda solution is added until the 
characteristic red no longer appears on the porcelain dish; the per- 
centage of HCl is obtained by multiplying each c.c. of decinormal 
solution used by 0.00365 (for each c.c. of the decinormal solution is 
neutralized by 0.00365 of HCl), and again multiplying by 10. (c) 
To 10 c.c. of gastric contents is added a few drops of the indicator 
(0.5 per cent, solution of dimethylamidoazobenzol in strong alcohol) ; 
it is placed in a beaker and, if free HCl is present, the yellow color 
imparted by the indicator will change to bright red; a decinormal 
solution of caustic soda (4 gm. to 1,000 c.c. of distilled water) is then 
added drop by drop to the gastric contents, until the color of the in- 
dicator has been changed from red to bright yellow; the number of c. c. 
of decinormal solution used is multiplied by 0.00365 and again by 10 to 



604 DISEASES OF THE DIGESTIVE TRACT 

give the amount of free HC1. Very often the result is expressed in 
terms of the number of c.c. of decinormal solution used; i.e., if 4 c.c. 
were employed, 4 x 10 = 40, the free HC1. The usual amount is 30 to 
40. 

The total acidity (HC1, lactic and other organic acids, acid phos- 
phates and albumins, albumoses and peptones) is estimated by adding 
two drops of a 1 per cent, alcoholic solution of phenolphthalein (as 
an indicator) to 10 c.c. of the gastric contents; to this is added, drop 
by drop, a decinormal solution of caustic soda (4 gm. to 1,000 c.c. of 
distilled water) until the red color, due to the alkali acting upon the 
phenolphthalein, no longer disappears on gentle shaking; this, how- 
ever, is not the true end reaction, for the decinormal solution must be 
added till the rose-red color is no longer even deepened in hue by the 
alkali. As 4 to 8 c.c. of the decinormal solution are usually required, 
4. or 8 x 10 = normal total acidity; i. e., 40 to 80 expressed in terms of the 
decinormal solution (corresponding to 0.15 to 0.25 per cent. HC1). 
If the acid reaction of the gastric contents is due to HC1 alone, and no 
organic acids are present, each c. c. of the decinormal solution cor- 
responds to 0.00365 gm. HC1 and therefore the number of c.c. re- 
quired to neutralize the gastric juice x 0.00365 x 10 = the per cent, of 
HC1. In most cases determination of the total acidity is sufficient. 
A total acidity under 20 gives no reaction with Congo paper; i. e., there 
is no free HC1. The bread of the test breakfast (phosphates chiefly) 
accounts for the acidity of 5 to 6 ; if the total acidity ranges from 5 to 8, 
we may be almost certain that the gastric glands are atrophied. 

Combined Hydrochloric Acid. — "The method elaborated by Cohn- 
heim and Krieger, modified by Fisher, is accurate and convenient. 
The method is as follows; Determine the total acidity by titrating 5 
c.c. of the gastric filtrate with 0.1 normal NaOH solution, using a 1 per 
cent, alcoholic solution of phenolphthalein as an indicator. Takeanother 
5 c.c. of the filtrate and sufficient calcium phosphotungstate solution to 
make 20 c.c. and call this Ta t . Let it stand three or four minutes, add 
animal charcoal, and filter. Determine the total acidity of this filtrate, 
using a 1 per cent, solution of rosolic acid as an indicator; call this Ta 2 . 
Then Tai minus Ta 2 equals the combined HC1 in the 5 c.c. of the 
filtrate of the gastric contents used. If the gastric contents show an 
absence of free HC1, proceed as follows : 

1. Determine the hydrochloric acid deficiency by adding 0.1 normal 
hydrochloric acid, using a 1 per cent, alcoholic solution of dimethyl- 
amidoazobenzol as an indicator. Determine the total acidity of this 
mixture, using phenolphthalein as an indicator. This total acidity 
minus the quantity of hydrochloric acid added will give the original 
total acidity of the 5 c.c. of the filtrate of gastric contents employed. 

2. Take 5 c.c. of the gastric filtrate, add 0.1 normal hydrochloric 
acid sufficient to make the new total acidity at least 60 per cent. ; add 
sufficient calcium phosphotungstate solution to make 30 c.c, and 
titrate with rosolic acid as an indicator, calling the resulting acidity Ta 3 . 
The difference between Ta 3 and Ta 2 will represent the quantity of 



CHRONIC GASTRITIS 605 

hydrochloric acid combined with all the albumin in the 5 c.c. of 
gastric nitrate employed. Call this total CHC1. Then this total CHC1 
minus the hydrochloric deficiency equals the combined HC1 in 5 c.c. 
of the gastric filtrate. 

Employed subacid gastric contents 5c. c. 

HC1 deficiency (dimethylamidoazobenzol) 1 " ==20 

Total acidity (phenolphthalein) 3 " =60 

Original total acidity (60-20) " =40 

Ta x Added HC1 in excess 3 " = 60 

Added calcium phosphotungstate 18 " = 

Ta 2 Total acidity (rosolic acid) of 30 "=30 

Total CHC1 Total possible combined HC1 (60-30) "=30 

Actual combined HC1 in gastric contents . . . .(30-20) " =10 

Ta 2 — Ta 3 = Total HC1. 

Total CHC1 — HC1 deficiency = combined HC1." (Musser, Medical 

Diagnosis.) 

In chronic gastritis the hydrochloric acid is found decreased, or even 
absent by these tests. In a few cases, as described by Riegel and Boas, 
the acid is normal, showing a total acidity of 43 to 56; this form is 
called gastritis acida, though its separation as a type is scarcely justi- 
fiable; these are* usually light or incipient cases and probably some of 
them are neurotic. 

(c) Rennet and pepsin are rarely totally absent, though usually 
decreased. Pepsin is tested by mixing the gastric juice with egg al- 
bumin; 25 c.c. of normal gastric juice will dissolve 0.05 gm. of serum 
albumin in one hour, the same amount of fibrin in one and one-half 
hours, and of egg albumin in three hours; Petit claims that pepsin will 
dissolve 500,000 times its weight of fibrin in seven hours. Pepsinogen 
is tested in the same way with the addition of a few drops of hydro- 
chloric acid, which liberates the enzyme (pepsin) from the pro-enzyme 
(pepsinogen). Boas especially has insisted on the importance of the 
rennet ferment, which coagulates milk; if no rennet is present, the 
gastric filtrate will not coagulate milk. 

Lactic acid is seldom found (see Cancer of Stomach). The mo- 
tility of the stomach is unimpaired. Leukocytes and epithelial cells 
are found at times, and in rare cases shreds of gastric mucosa (Gas- 
tritis exfoliativa, Parisier). 

4. Other Symptoms.— (a) Vertigo e stomacho laso (Trousseau), — 
gastric vertigo, is probably neurasthenic rather than gastric. The so- 
called dyspeptic asthma is not really asthma, but a dyspeptic dyspnoea, 
and probably results from pressure of the distended stomach on the 
heart. Headache, physical and mental lassitude, a degree of melan- 
cholia, intercostal neuralgia, tender points between the shoulders or over 
the lower cervical spines, and palpitation, are fairly common, (b) The 
bowels are generally constipated; diarrhoea and tympany at times 
result from marked gastric fermentation or extension of the catarrh 
to the gut, when catarrhal icterus may result. Boas and Schmidt find 
regularly undigested connective tissue in the movements, (c) The urine 
is frequently reduced and shows a lateritious deposit, phosphates and 
oxalates, (d) The general nutrition is usually fairly well maintained 



606 DISEASES OF THE DIGESTIVE TRACT 

if the intestines functionate well, (e) The motive and absorptive 
power of the stomach is variously regarded; it may be impaired, normal, 
or even exaggerated, the food being sometimes hurried into the intes- 
tine. 

Diagnosis. — Leube insists that chronic gastritis should never be 
diagnosticated until cancer, ulcer and functional disease have been 
finally excluded. Its cardinal points are (a) its steady, slow, chronic 
course; (6) the presence of mucus, and (c) decreased secretion. (For 
its differentiation v.i. Ulcer.) 

Treatment. — 1. Prophylaxis. — Recurrence of the trouble is pre- 
vented by treatment of the causal conditions; digitalis is indicated in 
gastric stasis of cardiac origin, and iron in anaemia. 

2. Hygiene. — Hygiene concerns regularity in living, moderation, 
recreation, massage, rational exercise, and avoidance of haste in eating. 

3. Diet. — F.A.Hoffman justly remarks that every one "has the 
stomach he deserves." Slowness of eating, drinking only after the solid 
part of the meal is eaten, and thorough mastication, are frequently 
curative with no medicinal treatment. The importance of thorough 
insalivation of the food is manifest when we remember that the ptyalin 
operates for nearly an hour in the unchurned contents of the cardiac 
end of the stomach. As Ewald states, "die Diat der Magen-Kranker 
fangt im Munde an. " The teeth should receive such care as the treat- 
ment of pyorrhoea, extraction of carious teeth, and fitting of proper 
plates. Food should be taken in moderate amounts, and the stomach 
should be given sufficient rest, though most dyspeptics do not eat 
enough (von Noorden). Pawlow has shown that the relish of food 
excites the flow of the gastric juice; he names it the "appetite juice." 

Kind of Food — The term "easily digestible food" is extremely 
relative, but the kind of food is less important than careful mastication 
and insalivation. In severe or alcoholic cases an absolute milk diet 
may be tried, giving equal parts of milk and Apollinaris water, to which 
grains x of sodium bicarbonate, grains x of sodium chloride, and grains 
v of magnesia levis are added. Predigested milk and Mosquera's beef 
jelly (see Typhoid) soon become distasteful to the patient, and are in- 
dicated chiefly in severe catarrh with much mucus formation or with 
atrophy. Generally speaking, the diet should be mixed, but proteids 
are superior to carbohydrates, which are prone to ferment. The pro- 
teids which may be given are chopped lean meats, scraped beef, boiled 
mutton, veal, roasted steak, broiled tenderloin, pigeon, chicken, eggs 
boiled one minute, somatose, and nutrose. Chittenden has shown that 
we eat twice as much meat as is necessary. Beef tea, heavy fresh beef, 
hard-boiled eggs, pork, game, fish, warmed-over (therefore hardened) 
meat, turkey, goose, duck, smoked or cured meat (possibly except- 
ing bacon) and cheese must be interdicted. Carbohydrates are to 
be withheld when there is obstinate fermentation. Those which may 
be allowed are arrowroot, well cooked sago, tapioca, or rice, white bread, 
zwieback, and toast; those which may be occasionally allowed or tried 
later are mealy potatoes, spinach, pea or bean soups; those to be for- 



CHRONIC GASTRITIS 607 

bidden are substances containing much cellulose, hard bread, brown 
bread, oatmeal, coarse vegetables, uncooked green vegetables, most 
fruits, pies, and pastries. It is interesting to note that most of the carbo- 
hydrates ingested usually reach a maximum amount in the intestine in 
two hours (some reach the bowel in ten minutes), which time is twice 
the maximum time for proteids and two and a half that for fats. Carbo- 
hydrates, therefore, should be eaten before the proteids, that they may 
the earlier leave the stomach. Fats are a necessary part of the diet, 
especially moderate amounts of butter and cream. Von Noorden in- 
sisted on their use. Other forms of fat are injurious. Greasy soups 
are to be avoided. 

Accessories. — No seasoning is necessary, but liberal quantities 
of salt may be used. Liebreich insists that condiments in moderate 
amounts are helpful. Tea, coffee and alcoholic beverages are usually 
prohibited. Smoking should be interdicted or restricted. 

4. Gastric Lavage. — Lavage is indicated when there is formation of 
mucus, fermentation, deficient secretion, and delayed digestion. It is 
generally considered the most helpful measure but in the writer's experi- 
ence is seldom indicated as there is no stagnation of food. Morning 
lavage is best for removal of mucus, and lavage before the evening meal 
for delayed digestion or fermentation. Warm water is used, to which 
sodium chloride or bicarbonate, two spoons to the quart, may be added 
to dissolve the mucus, or salicylic acid (1 to 1,000) to modify fermen- 
tation. The stomach should be washed until the water returns clear. 
When the use of the stomach tube is resisted or contra-indicated, as by 
exceptional nervousness, modified lavage may be employed, the patient 
drinking before breakfast two glasses of warm water to which a 
teaspoonful each of sodium chloride and sodium bicarbonate has been 
added. This process is essentially the same as drinking the Kissingen, 
Wiesbaden, and other waters. The sodium bicarbonate acts locally, 
and the sodium chloride acts both locally and systemically, for small 
doses increase the hydrochloric acid and large doses reduce it by in- 
creasing the alkalinity of the blood. Carbonated waters may be used, 
which stimulate secretion and absorption and neutralize abnormal 
acids. 

5. Medical Treatment. — (a) The value of hydrochloric acid is disputed. 
Its first indication is to convert pepsinogen into pepsin, whence it is use- 
less in atrophic gastritis save as it stimulates the flow of bile. Its second 
indication is as a digestant; many specialists deny that it has this 
action, maintaining that sufficiently large amounts cannot be given; 
but Stewart in his excellent articles says that he employs doses of 20 
drops and gives them every twenty or thirty minutes until 5 j to ij have 
been given. Its third indication is as an antizymotic, which Boas holds is 
its sole indication ; it should not be given until about half an hour after 
meals, during which period the saliva is acting upon the carbohydrates ; 
some writers incline to the view that at the best hydrochloric acid is only 
a stomachic, but Pawlow has shown that it increases the flow of pan- 
creatic juice and perhaps of bile, (b) Boas takes the extreme view that 



608 DISEASES OF THE DIGESTIVE TRACT 

pepsin is useless. It should be given as a powder, for solutions rapidly 
deteriorate and are usually strongly alcoholic. Like malt preparations, 
many forms offered on the market are inert. Pancreatin is very fre- 
quently ineffective. Taka-diastase is beneficial in some cases, (c) 
Bitters are best exhibited before meals; though their mode of action is 
disputed and their stimulation of secretion has been denied, they surely 
act upon the appetite or on the nervous structures, and increase the 
flow of saliva and gastric juice and probably also the pancreatic juice. 
Strychnine or nux vomica is the best of this group of drugs and is 
especially valuable in alcoholic cases. All bitters should be given in 
solution, as their bitter taste is their chief mode of action. 

Strychninae sulphatis gr. j . 

Acidi nitrohydrochlorici 3j. 

Tr. gentianse comp §iv. 

M. et S. — One teaspoonful half an hour after meals in half a glass of water. 

Condurango bark (fluid extract 5 SS ) * s prepared. by macerating the 
bark in cold water. Some bitters, as gentian, may irritate the stomach 
and induce diarrhoea, (d) Antizymotics (antifermentatives), as creo- 
sote or beta-naphthol, often cause irritation. Carbolic acid gr. j, 
thymol gr. ss to j, resorcin gr. ij to v, after meals, act on the stomach, 
and salol gr. x and beta-naphthol gr. x (in capsule because of its bitter- 
ness) are intestinal antiseptics, (e) Gastric sedatives are seldom in- 
dicated except in the hyperacid type. Bartholow's combination (see 
Acute Gastritis) meets all indications. Silver nitrate is sedative, astrin- 
gent, and alterative, but may cause nephritis or argyria; it is given in 
pill form, half an hour before meals, in doses of one-fourth of a grain 
(perhaps with quite small doses of opium or belladonna). Zinc oxide, gr. 
iij to v, given before meals, is valuable in alcoholic gastritis. Extract of 
belladonna in one quarter of a grain doses is helpful in pain, especially 
in hyperacid gastritis. Pyrosis and spasm may be considered under 
this heading. In pyrosis of fatty and other organic acids, alkalies may 
be employed, though sparingly; Trousseau gave sodium bicarbonate 
grains v, creta preparata grains x, and magnesium carbonate grains v 
after meals. Spasm from gas or overloading of the stomach is modified 
by spirits of chloroform tt# xx and tincture of asafoetida 5j; spasm 
suggests erosions near the pylorus, when extract of belladonna gr. J 
and subnitrate of bismuth gr. x are distinctly indicated, after meals. 
(/) Other measures, as faradization, massage, and hydrotherapy, are 
less valuable than in gastric atony and sensory neuroses of the stomach. 
In constipation cathartics should be avoided, as they cause irritation 
and constipation recurs. Hot water, gastric lavage, colonic flushings, 
and perhaps the mildest saline aperients, are indicated. 



ACHYLIA GASTRICA 609 



Achylia Gastrica. 

Etiology. — The term was introduced by Einhorn in 1892 to designate 
total suppression of gastric digestion. Atrophy of the stomach was 
first described by Austin Flint (1860) and by Fenwick (1877), Ewald, 
Quincke, and Einhorn. It most frequently occurs secondarily in can- 
cer of the stomach and in toxic gastritis, but also in other gastritides, 
cancer of distant organs (mammae, uterus, intestine, oesophagus), 
diabetes, pernicious anaemia, tabes, and in neuroses. In rare cases it 
develops as a seemingly primary affection, possibly as a congenital 
condition (Martius). It occurs oftenest in middle or advanced life, 
though isolated cases are reported at eighteen to twenty-five years of 
age. 

Pathology. — Pathologically two main forms exist, (a) one cirrhosis 
ventriculi, in which the stomach is very small and thickened so that its 
walls may measure several centimeters in thickness, and (b) another, 
phthisis ventriculi, in which the walls are thin or "wasted" and the 
stomach is lax or dilated. In some cases atrophy has been found in 
Meissner's and Auerbach's plexuses. The glandular structures are 
wasted (anadenia). 

Symptoms. — Symptoms may be absent if gastric motility is good 
and the intestinal glands are normal (von Noorden). If the same pro- 
cess exists in the gut, diarrhoea, marasmus and death result. 

1. Gastric Symptoms. — There are no pathognomonic gastric symp- 
toms. Pain is variable; it may be absent or moderate, though in 
some cases lancinating pain and other symptoms like those of hyper- 
chlorhydria may exist (Einhorn). The appetite is also variable. Vomit- 
ing does not always occur but when present the vomitus always 
contains coarse, poorly digested particles. 

2. Test Meal — The recovered food is coarse; the total acidity is 
1 to 4, corresponding to the amount in the food ingested. No HC1 
is found (achlorhydria), no pepsin (therefore no peptones), no rennet 
(therefore no coagulation of milk), no blood, and according to most 
writers no mucus ; according to Riegel and Schmidt, some mucus may 
be present, due to metaplasia of the gastric mucosa to one resembling 
that of the intestine, the cells of which secrete mucus ; as they in turn 
atrophy the mucus disappears. Lactic acid is found but rarely. 
The gastric motor power is usually unimpaired, and the stomach is 
often emptied in less than an hour. In the contracted cirrhotic form, 
the stomach may hold but a few ounces; in the phthisic form ectasia 
may occur. In some scleroses of the stomach a sound is introduced 
into the stomach with difficulty, hydrochloric acid is present, the 
stomach cannot be distended with gas, and its capacity is enormously 
decreased. 

3. Other Symptoms. — Headache and vertigo are common. Con- 
stipation is the rule; in some cases diarrhoea may be the sole salient 
symptom, so that it apparently indicates an intestinal lesion (Oppler). 

39 



610 DISEASES OF THE DIGESTIVE TRACT 

Symptoms like those of pernicious ansemia (Henry and Osier) or like 
gastric cancer (author) mark some cases. The acidity of the urine 
which is normally present at the height of digestion, is naturally ab- 
sent. The test meal establishes a clear diagnosis. 

Prolonged observation may be necessary in order to exclude the 
secondary atrophic gastritis of cancer. Amyloid gastric disease and 
nervous aclrvlia are eliminated by consideration of other somatic 
findings or symptoms. 

Prognosis. — Life may be prolonged for years by compensating 
intestinal digestion, but recovery is impossible after actual atrophy 
develops. 

Treatment. — Treatment is necessarily palliative. Thorough masti- 
cation of food is imperative. Cellulose is to be avoided, and thick, 
plain, leguminous purees should be given. Butter is well tolerated. 
The meals should be small and frequent (every three or four hours). 
HC1 should be given in full doses (tt^xx to xxx), Pawlow having demon- 
strated its stimulating action on the pancreatic flow. Water relieves 
the pain, which resembles that of hyperchlorhydria (Einhorn). 



(C). DILATATION OF THE STOMACH; MOTOR INSUFFICIENCY. 

The nomenclature of this and allied conditions is a matter of dispute; 
dilatation of the stomach (gastrectasia) is only a symptom, and is 
understood as a more or less lasting dilatation with motor insufficiency. 

1. Acute Dilatation. 

Acute dilatation and atony (loss of muscular tone) are rare, but 
have been observed by Fagge, Fraenkel, Hunter, Osier, and Boas. 

Somewhat over 50 cases of acute dilatation are recorded. 

Etiology. — (1) Most cases follow abdominal trauma or laparotomy 
(36 per cent, according to C. Thompson); gall-bladder operations 
are the most frequent type. The two cases seen by the writer were in 
women over fifty years of age who had been operated for fibroids of 
the uterus. (2) It may follow acute infections as pneumonia or 
typhoid; or (3) overloading of the stomach; in one of Kolisko's autop- 
sies in Vienna, the author saw an enormously dilated stomach in a 
man who had, on a wager, taken a large number of charged siphons, 
and died soon afterward from gastric distention and reflex paralysis 
of the heart. (4) Most cases occur between twenty and thirty years 
of age. (5) Traction or obstruction of the superior mesenteric vein 
is the most favored etiological factor. 

Symptoms. — The stomach is enormously distended; there is vomit- 
ing of brown-gray to black material which often runs out of the mouth, 
may be very copious and sometimes is offensive. There is usually no 
free H CI; sometimes there is lactic acid ; succussion sounds are fairly 



CHRONIC DILATATION AND MOTOR INSUFFICIENCY 611 

frequent. The abdomen is greatly distended. There is much collapse 
and often abdominal pain. 

Prognosis and Treatment. — Eighty-five per cent, die, and usually 
within a week. The indications are : early gastric lavage ; rectal feed- 
ing; strychnine in large doses and a few doses of atropine (under which 
the writer observed one recovery); salt solution under the skin, and 
other measures for shock ; and in appropriate cases gastrostomy or gas- 
troenterostomy. 

2. Chronic (Permanent) Dilatation and Motor Insufficiency. 

In the following discussion it must be borne in mind that various 
grades of distention and atony may occur, that dilatation may be asso- 
ciated with increased power of the gastric musculature or with atony, 
and that motor insufficiency (inability of the stomach to propel food 
into the intestine) is not necessarily, though very often, associated 
with dilatation of the stomach. Dilatation and motor insufficiency are 
most prevalent in middle or advanced life. 

Etiology. — 1. Pyloric Stenosis. — Its causes and symptomatology are 
varied. It is most often cancerous, but may also follow round or cor- 
rosive ulcers, chronic gastritis leading to hypertrophy of the pyloric 
musculature (stenosing gastritis), benign tumors of the stomach, as 
pedunculated polyps occluding the pylorus, and congenital stenosis, of 
which Shaw and Elting (1905) collected 145 cases; under one year of 
age 45 cases of congenital hypertrophic stenosis are reported, most 
of which were less than four months old. It may also result from con- 
genital duplicature of the pyloric mucosa, from rotation of the stomach 
on its axis, from angular bending of the fixed pylorus by sinking of 
the stomach (gastroptosis), or from adhesions due to cholecystitis. 
Ricard and Chevrier collected nineteen cases of tuberculous pyloric 
obstruction. Stenosis of the duodenum produces essentially the same 
results as pyloric stenosis and may follow duodenal ulcer, diverticulum, 
or twisting. The pylorus may suffer compression stenosis from tumors 
of the liver, colon, kidney, or pancreas. Temporary or permanent 
pyloric spasm (v. Gastric Neuroses) from fissure, erosion, ulcer, or 
hyperchlorhydria may cause the obstruction. Payr in 1904, collected 
58 cases in which pyloric stenosis was associated with intestinal stenosis 
(chiefly from round ulcer). The pathological sequence of pyloric 
stenosis is retention of food within the stomach and hypertrophy of 
its musculature in attempts, sometimes partially successful and at 
other times vain, to force the food through the narrow or closed pylorus. 
The analogy is close between this change and that observed in hyper- 
trophied and dilated bladder from prostatic enlargement, or hypertrophy 
with dilatation of the heart in obstructive valvular disease. In all 
three instances the hypertrophied muscle eventually degenerates. 
Dilatation of the stomach may be considered, then, as a disturbed 
compensation. 



612 DISEASES OF THE DIGESTIVE TRACT 

2. Muscular weakness (motor insufficiency, insufficiency of the 
stomach, hypotony, atony, myasthenia gastrica), constitutes, in con- 
trast with the first group of causes, a functional and, generally speak- 
ing, a more reparable type, (a) Atony dependent on general causes 
may occur in acute infections, hysteria, neurasthenia, anaemia, and 
possibly in cerebrospinal disease. The atonic tendency may be ac- 
quired or congenital. Rickets is thought to cause certain juvenile 
cases, (b) Atony may result from gastric conditions, as trauma, can- 
cer, gastritis, hypersecretion, peritoneal adhesions, cholecystitis with 
pyloric adhesions, diaphragmatic pleurisy, and diastasis of the musculi 
recti abdominales. Overloading the stomach with heavy meals, eat- 
ing indigestible foods or excess of vegetables and carbohydrates, beer 
drinking, milk in large quantities, much water ingested with heavy 
meals, as in diabetics, swallowing of foreign bodies by insane subjects, 
etc., may develop muscular insufficiency. The stomach is usually 
enlarged, contains residual food, and shows a lax, often wasted and 
thinned musculature. 

Symptoms. — The symptoms of dilatation (again emphasized to be 
a symptom only) differ greatly in degree, ranging from absolute pyloric 
stenosis to the least motor weakness. The symptoms are partly me- 
chanical, partly chemical. 

1. Gastric Symptoms. — (a) The condition of the tongue is variable; 
it is sometimes coated, sometimes clear, (b) The appetite is also 
variable, (c) There is usually thirst and dryness of the throat, more 
frequently in hypersecretion than in cancer, (d) Singultus, pyrosis 
of fatty acids, oppression over the stomach, a cramped feeling or one 
of unrest, and eructation of various gases, are frequent. Gases are 
never formed without motor insufficiency; the kind of gas is of more 
scientific than clinical interest, but includes hydrogen sulphide, hydro- 
gen, oxygen, nitrogen, carbon dioxide, and even inflammable gases. 
(e) Vomiting is always present in pyloric obstruction and in marked 
motor insufficiency. It occurs easily, and is often rather belched up 
than vomited. It occurs when the stomach is full, frequently during 
the night or at intervals of days; five quarts may be evacuated. It is 
acid, sour, and often greatly decomposed. Three layers are noted, a 
brownish foam, a gray-brown fluid, and a sediment of food, stones, and 
seeds, which may have lain for days in the stomach. Gas often bubbles 
up as the vomitus stands. If gastric juice only is found, it indicates 
hypersecretion with motor insufficiency. Chemically, butyric acid, 
peptones, and, in cancer, lactic acid, are found; when the obstruction 
lies in the duodenum below the papilla of the common duct, bile is 
also present. Microscopically undigested meat or starch, in benign 
stenosis sarcinse, and in cancer the Oppler-Boas (lactic acid) bacilli, 
yeast, and other bacteria, are found. HC1 is absent in cancer. (/) 
Pain is frequent; it is cramp-like, boring or burning. 

2. Test Meal, Motility, and Resorption. — (a) The chemism depends 
on the causal affection, particularly if it is gastric (see Gastritis, Ulcer, 
Cancer, Hyperchlorhydria, Hypersecretion). Hyperchlorhydria 



CHRONIC DILATATION AND MOTOR INSUFFICIENCY 613 

and hypersecretion (except in malignancy) are usually present and are 
sequential rather than causative. (b) Motility is best tested by Leube's 
test dinner, consisting of 13 ounces (400 c.c.) beef soup, 7 ounces 
(200 gm.) beefsteak, one to two ounces (60 gm.) bread, and 7 ounces 
(200 c.c.) water, which should leave the stomach physiologically in 
not^more than seven hours. If food is found somewhat later, stagna- 
tion is present; if found in the morning when Leube's meal has been 
given at night, there is great stagnation. The long stay of food in the 
stomach shows practically what the vomitus shows, i. e., fermentation. 
Fluid is not absorbed by the stomach, whence the measure of its resid- 
ual amount is important. There is more fluid in the stomach than was 
ingested, which is accounted for by hypersecretion of the gastric juice, 
actual transudation, mucus and perhaps regurgitation from the intes- 
tine, or hemorrhage. Other tests are less reliable; — the oil test consists 
of administering three ounces (100 c.c.) of olive oil, 70 to 80 per cent, 
of which should leave the stomach in two hours; if more than 20 to 
30 c.c. remain after this time, it is indicative of motor insufficiency. 
Salol, grains xv, given just after eating, should normally reach the 
intestine within an hour, where it is split up into salicylic and carbolic 
acids; in testing the urine passed in forty-five to sixty minutes after 
eating, salicyluric acid should be found (reacting violet to tincture of 
the chloride of iron) ; salol is normally eliminated in twenty-four hours, 
and its presence in the urine for a longer time also indicates delayed 
absorption and dilatation; two errors are possible in this test, viz., 
its possible decomposition by alkaline mucus in the stomach, and its 
failure to decompose in the gut when there is acid intestinal fermen- 
tation (Brunner and Huber). Resorption may be tested by giving 
five grains of potassium iodide after eating. It should be absorbed 
and secreted by the saliva in seven to fifteen minutes; this is tested 
by adding nitric acid to the saliva and touching with starch paper, 
which will show the blue iodine reaction; a possible error is the 
prompt absorption of the KI when food is not absorbed. In general 
a well-worked-up homogeneous chyme means that the motor function is 
normal ; coarse particles occur when there is motor insufficiency. 

3. Physical Signs. — (a) Inspection in a good light is very important. 
A visible prominence of the dilated organ may be seen below the navel, 
sometimes showing clearly the abnormally low upper and lower cur- 
vatures, the upper curvature never being seen normally. In obstruction 
a peristaltic wave passing from left to right, or an antiperistaltic 
wave in the opposite direction, often tells the whole story. "Stiffen- 
ing" of the stomach is an infallible sign of pyloric stenosis. Peristaltic 
waves may be elicited by applying ether or ice to the epigastrium. 
The a>rays show the outline of the viscus after ingestion of consider- 
able bismuth. (b) Palpation confirms the above findings and also 
elicits splashing (clapotage) of gas and water in the stomach, a sign on 
which no great reliance is placed, for splashing occurs in healthy 
stomachs. The hand may palpate the final gush of gastric contents 
into the gut. (c) Percussion — The normal vertical dimension of the 



614 DISEASES OF THE DIGESTIVE TRACT 

stomach is 4 to 5.5 inches (10 to 14 cm.) and its maximum capacity 
three pints (1.600 c.c). Filling the stomach with water and percussing, 
with the patient standing, outlines both the lesser and greater curvatures, 
which may even reach to the pubes. Siphoning the water and then 
distending the stomach with air pumped in, or with carbon dioxide 
gas, replaces the flatness by tympany. (The carbon dioxide is pro- 
duced by giving sodium bicarbonate 5j to ij dissolved in water, fol- 
lowed by an equal amount of tartaric acid in water.) When doubtful, 
the colon may be distended with gas or fluid. The greatest distention 
is at the fundus. With both gas and water in the stomach, the note 
changes with change of posture, the fluid being in the lower and the 
gas in the upper parts, as in ascites; the most experienced men ac- 
knowledge that they have confused enormously dilated*stomachs with 
ascites and ovarian cysts and have introduced a trochar; Jadon pub- 
lished a case in which the stomach contained 45 quarts. Leube was 
the first to palpate the lower end of the stomach by means of a rigid 
sound; this has justly been practiced less frequently of late years; 
the normal distance from the upper teeth to the greater curvature is 
23.5 inches (60 cm.) which is increased in dilatation to 27.5 inches 
(70 cm.) or more, (d) Auscultation elicits the splashing which may 
be heard by the patient, and sometimes a fine crepitation or hissing 
noise as gas is generated, a splashing or dripping sound as the patient 
drinks, or metallic heart tones. The arrays and gastric illumination 
are less certain and easy methods of diagnosis. 

4. Complications. — (a) Constipation is the rule, and the stools are 
hard, because less fluid passes the pylorus. (6) The urine is often 
alkaline, its chlorides are lessened, and its amount is reduced to a 
pint or less as a result of the acid vomiting; triple phosphates are 
common and acetone and diacetic acid are occasional, (c) The skin is 
often dry, and (d) emaciation is common, even in benign stenosis or 
muscular insufficiency, because food is imperfectly absorbed; some of 
it is lost to the organism by fermentation and tissue-destroying toxins 
possibly develop, (e) Auto-intoxication from fermentation may de- 
velop, causing headache, vertigo, drowsiness, psychoses, polyneuritis, 
tetany, slow pulse, and nervous dyspnoea. Tetany (Neumann and 
Kussmaul) occurs oftenest in hypersecretion or stenosis from cancer 
or ulcer; its symptoms are considered under Tetany, and it may be 
merely noted here that 73 per cent, of cases die (101 cases combined 
from Riegel, Albu, Fraenkel-Hochwart, etc.). 

Diagnosis. — The etiology, vomiting, impaired motility as shown by 
Leube's test dinner, the visible outlines confirmed by percussion, and 
the low lesser curvature which is not seen normally, distinguish gastrec- 
tasia easily; its cause may be determined with difficulty only. The 
stomach may be physiologically large (megalogastria), but then there 
is no motor insufficiency, no vomiting, and no stagnation. Gastroptosis 
will be considered later. The degree of stasis is determined by wash- 
ing out the stomach at varying times after the test dinner. In pyloric 
stenosis there is greater dilatation than in simple motor insufficiency 



CHRONIC DILATATION AND MOTOR INSUFFICIENCY 615 

(or atony), and marked peristalsis is always indicative of obstruction. 
When a diagnosis of pyloric obstruction is established, the benign must 
be differentiated from the malignant type; benign pyloric obstruction 
runs a more remittent longer course, of over two years', even of fifteen 
years' duration; HC1 and the ferments are usually increased and are 
always present, sarcinse are often and lactic acid seldom present; in 
the writer's experience stenosis due to round ulcer is, in fully half the 
cases, attended by subacidity or anacidity; while in cancer (v.i.) the 
march of symptoms is unfortunately progressive, and cachexia, severe 
anaemia with leukocytosis, hydrops, pyloric tumor, the Oppler-Boas 
bacillus, and metastases, develop with relative rapidity. The spasmodic 
form runs an intermittent course. The prognosis depends on the 
etiology and amenability to treatment; spastic (spasmodic) types are 
curable; relative stenosis may somewhat improve. 

Treatment. — 1. Etiological factors, especially those of atony, should 
be treated. 

2. General measures, tending to tone the musculature, are (a) 
abdominal massage, which should be practised only when ulceration 
and inflammation are certainly excluded; (b) drugs, especially strych- 
nine, which is often combined with atropine and the application of 
an ice-bag to the epigastrium; ergot and creosote are less valuable; 
(c) hydrotherapy; (d) faradization of the stomach; external applica- 
tion is seemingly as efficacious and certainly less difficult than intra- 
gastric application, though opinions vary greatly; and (e) abdominal 
binders or supports. These five points in treatment avail only in 
atony. 

3. Gastric therapy is indicated, (a) Gastric lavage removes the 
fermenting contents, relieves the organ of pressure exerted by accumu- 
lated food and fluid, cleans off the mucus, lessens vomiting and auto- 
intoxication, and may permanently help atony and temporarily mitigate 
the effects of pyloric stenosis. The stomach should be washed with 
luke-warm water until it returns clear of food and mucus; salicylic 
acid and sodium bicarbonate may be added, as in chronic gastritis; 
the patient soon becomes accustomed to the tube and welcomes the 
relief afforded; it is generally said that morning lavage is best, but 
washing before the evening meal is preferable, as the organ then suffers 
less stagnation through the night; the stomach should rest for a few 
hoi^rs before food is taken, (b) The food should be well divided, 
nourishing, and not too voluminous; it should be given with very 
moderate quantities of water, in small amounts and at intervals of 
three to four hours. The average diet consists of meat, eggs, legum- 
inous purees, very thoroughly cooked rice, and small amounts of butter; 
generally speaking, fats and carbohydrates are more prone to fermen- 
tation. P. Cohnheim advises an ounce or two of olive oil in pyloro- 
spasm and in moderate benign stenosis. A dry diet was early advised 
by von Swieten, but moderate amounts of fluid aid in propulsion of 
food into the gut. Of course much depends on the causal disease; 
a fluid diet is indicated in great pyloric stenosis, and when the hydro- 



616 DISEASES OF THE DIGESTIVE TRACT 

chloric acid is decreased. Meat should be given if the hydrochloric 
acid is normal or increased and the pylorus is not greatly stenosed. 
Recently there has been a reversion in favor of one or two fair-sized 
meals a day, thus giving the stomach ample time to empty itself and 
to rest. Water is not absorbed by the stomach, as proven by von 
Mering, who also found that the absorption from the stomach of sugar, 
peptone, dextrin, and alcohol, is attended by actual excretion of water 
into the stomach. Riegel believes a small amount of water is bene- 
ficial. In pronounced cases peptonized milk and water are given by 
rectum to supplement gastric feeding. In all cases careful individuali- 
zation is indicated; the exact degree of insufficiency should be tested 
by Leube's meal, i. e., the time required for absorption, and the patient 
should be fed accordingly, (c) Posture — The seriously affected patient 
should lie on his right side one to two hours after eating, thereby 
relieving pressure upon the greater curvature of the stomach and 
directing the food toward the pylorus, (d) Gastric medication — (See 
Chronic Gastritis, Ulcer, Cancer, Hypercblorhydria). (e) Thio- 
sinamin — (See Intestinal Obstruction). 

4. Surgical intervention is imperative in severe or malignant stenosis 
and when medical treatment fails. It embraces (a) pyiorectomy, of 
which Dryendorff collected 188 cases with a 57 per cent, mortality; 
(b) pyloroplasty (29 cases with a 21 per cent, mortality), (c) gastro- 
enterostomy (215 cases with a 43 per cent, mortality). In 153 opera- 
tions for benign stenosis Moynihan had only two deaths. As shown 
in ulcer and cancer (v.i.) the earlier recorded mortality has been much 
reduced. According to Shaw and Elting, in the pyloric stenosis of 
infancy the mortality under medical treatment is 72 per cent., under 
surgical 56 per cent. In eleven operations for tetany with pyloric 
stenosis (Jonnesco), eight cases recovered. 



(D). CHANGES IN FORM, SIZE AND LOCATION OF THE STOMACH. 

Form. — The antrum cardiacum and fore-stomach are oesophageal 
rather than gastric anomalies. The antrum cardiacum is a congenital 
bulging of the oesophagus just below the diaphragm, and the fore- 
stomach is a congenital dilatation above the diaphragm. There is a 
congenital form of narrowness of the pylorus as well as of hour-glass 
stomach. 

The acquired hour-glass deformity is more common and may result 
from spasm (hypertrophic muscle), cancer, ulcer, or adhesions around 
the middle of the organ, as well as from abdominal tumors, peritoneal 
tuberculosis, twisting of the stomach or hernia of it through the meso- 
colon. Mayo Robson (1904) in 23 cases found ulcer as the cause in 15, 
tumor in 4 and perigastritis in 4. It may co-exist with pyloric stenosis. 
Randolph and Thomas observed 2 cases in one family. 

Symptoms may be lacking in the lesser degrees of deformity; in the 
higher grades they are those of stenosis. (1) Only a part of a given 



CHANGES IN FORM, SIZE AND LOCATION OF THE STOMACH 617 

amount of water introduced into the stomach may be recovered 
(Wblfler's first symptom). (2) After the stomach has been washed 
till the water returns clear, the fluid may suddenly become clouded 
(Wolfler's second symptom). (3) The stomach is emptied by the 
stomach tube and yet splashing is obtained (from the cavity nearest 
the pylorus) ; Jaboulay called this paradoxical dilatation. (4) Inflation 
by carbon dioxide produces distention first of the left and later of 
the right half of the epigastrium (von Eiselsberg's first symptom). (5) 
Normally when the stomach is distended and the gas passes through 
the pylorus into the bowel, there is a sharp gurgle over the pylorus; 
in the hour-glass stomach the gurgle is heard two to four inches to 
the left of the median line (von Eiselsberg's second symptom). (6) 
On gastric distention by carbon dioxide Moynihan found tympany 
only over the upper part of the stomach and not over its lower half. 
(7) When the stomach is distended, a furrow may appear (Eichhorst 
and Schmid-Monard) ; Moynihan saw the furrow in 10 cases. (8) 
Filling the stomach with water and illuminating it by a light intro- 
duced into the stomach, the cardiac portion appears translucent and 
the pyloric part dark (Ewald). (9) A rubber balloon (introduced 
into the stomach and then inflated through the stomach tube) fills or 
outlines a part only of the stomach (Hemmeter). 

Treatment is surgical. Moynihan successfully operated on 23 cases; 
he enumerates the surgical measures as follows : single or double gastro- 
enterostomy, gastroplasty, gastrogastrostomy, partial gastrectomy, and 
dilatation of the stenosis. 

In situs viscerum inversus (see Diseases of the Heart) the pylorus 
lies on the left side. 

Size. — Megalogastria and microgastria are usually accidental find- 
ings if not associated with other gastric disease. 

Location. — The stomach at birth is vertical, and in adult life is 
generally held to lie so that three-quarters of it is to the left of the 
median line. Rosenfeld has recently insisted that the whole stomach 
is disposed to the left of the mid-line, and that the organ's physio- 
logical posture is vertical. 

Gastroptosis. — (See Enteroptosis.) 

(E). ROUND ULCER OF THE STOMACH. 

Definition. — Ulceration of the stomach is characterized in the 
majority of cases (a) etiologically by its occurrence chiefly in young 
women or in chloransemic subjects; (b) pathologically by a "punched 
out" funnel-like ulcer, oftenest near the pylorus, and (c) clinically by 
localized pain and tenderness, hsematemesis, and hyperacidity. 

Frequency.— It is found in 2.5 to o per cent, of all autopsies (W. H. 
Welch, Orth, and von Jaksch). It occurs four times less frequently 
in America than in Europe. 

Etiology. — The causes of ulcer are not exactly known, (a) Age 
and sex — Most cases (70 per cent., Lebert) occur between twenty and 



618 DISEASES OF THE DIGESTIVE TRACT 

thirty years of age, especially in women. Isolated cases occur in the 
very young and in the foetus; in children E. C. Cutler collected 29 
cases ; 60 per cent, occurs in women, in whom the disease occurs two 
to four times as frequently as in men. Ulcer develops most frequently 
in men between thirty and fifty years of age; the author has seen five 
cases in men over sixty, (b) Ancemia and chlorosis are strongly pre- 
disposing factors. Ansemia plus (c) hyperacidity are usually held to 
be important factors; the writer believes Rosenheim and Cohnheim are 
correct in stating that hyperacidity is only a result; 73 per cent, of 
Leube's cases of chlorosis showed hyperacidity, (d) Changes in the 
vessels are of etiological importance. As a normal access to the stomach 
of arterial blood prevents its autodigestion, it is thought by some that 
interruption in the local circulation is the cause of ulceration ; Virchow 
believed that embolism was causal, and Klebs held that arterial spasm 
was an etiological factor. Embolism is proven to follow burns. It 
will be noted, however, that ulcer often occurs at an age when arterial 
changes are rare, though syphilis, alcoholism, arteriosclerosis, cardiac 
and hepatic disease apparently cause some of the cases in later life. 
(e) Occupation is a factor. Many cases occur in servant girls and in 
cooks; (/) trauma in cooks, shoemakers, and in tailors, is an accessory 
factor, for the tasting of hot foods and pressure against the stomach 
promote the development of ulcer. (Some writers hold that there are 
two leading causes for ulcer: ansemia and pressure.) The pressure of 
corsets, the swallowing in certain trades of particles of iron, porcelain, 
and glass, and imperfectly masticated or improper food, may be brought 
under this caption. External trauma is a distinct factor, (g) Other 
alleged causes are heredity; vomiting, and even hysteria, have been 
considered as causal. Letulle and Martin hold that (h) bacterial 
necrosis causes ulcer, which is clearly shown by Dieulafoy's cases of 
pneumococcic hemorrhagic ulceration of the stomach. 

Pathology. — Scars indicating healed ulcers are three times as fre- 
quent at autopsy as open ulcers. The ulcer is known as ulcus simplex 
(to distinguish it from malignant, or syphilitic ulceration), ulcus 
rotundum, as the smaller ones especially are round, ulcus pepticum 
and perforans. The peptic ulcer occurs almost exclusively in the 
stomach, lower oesophagus, and upper duodenum. (See Duodenal 
Ulcer.) Its general morphology was first described by Cruveilhier 
(1829) and Rokitansky (1839); it has a "punched out," clean-cut 
appearance; in contour it is round or oval in small, and irregular in 
large, ulceration; it is usually small, but sometimes invades most of 
the surface of the stomach, and in one case it measured four by seven 
and a half inches; it is funnel-shaped in old cases; its apex is eccentric 
and is directed toward the serosa, its sides are terrace-shaped, and its 
floor is usually clean. In 80 per cent, the ulcer is single, though a case 
with as many as 34 ulcers has been reported. Extension is more 
common in acute than in chronic cases and is more toward the peri- 
toneum than laterally. Microscopically there is usually.no infiltration 
with round cells. Its localization is chiefly near the pylorus on the 



ROUND ULCER OF THE STOMACH 619 

posterior wall or lesser curvature; its complications, as hemorrhage 
and perforation, and its sequela, as pyloric stenosis and deformations, 
will be considered under clinical symptoms. 

Symptoms. — The general clinical picture varies, cases being typical, 
doubtful, or entirely latent. 

In the typical case the symptoms develop gradually with a sense of 
epigastric pressure after eating, which later becomes a more violent, 
cutting, localized pain; this is observed less commonly directly after 
eating than one-half to one and a half hours thereafter; it lasts through- 
out the period of digestion and ceases only with passage of the food 
into the bowel or after vomiting. The appetite is usually good ; hyper- 
acidity is noted after a test meal or in the vomitus; focal tenderness 
occurs over the epigastrium, and in fully half the cases bleeding from 
the stomach or'blood in the stools is observed. 

The typical triad of cardinal symptoms, taken together or possibly 
singly, makes the diagnosis most easy; (1) pain with localized tender- 
ness, (2) hsematemesis, and (3) hyperacidity. 

1. Pain. — The most important, characteristic and constant symptom 
is pain, which is usually paroxysmal, is localized, and occurs during 
digestion. It is boring or burning, seldom lancinating, and is due to 
irritation of the gastric nerves aroused by peristalsis, nerve erosion, or 
hyperacidity. The diet affects the pain greatly; milk, for instance, is 
well tolerated in certain cases, but solid food usually produces exces- 
sive pain, and very hot or very cold foods or beverages almost invariably 
cause discomfort. This disappears quickly with rectal feeding. The 
seat of the pain varies in different patients, but is always the same in a 
given case. In the great majority of cases it is epigastric and is very 
often quite near the ensiform. Ewald and others describe it as char- 
acteristically cramp-like in the pyloric region (in the right mammary 
line under the liver). Sometimes there is wide irradiation toward the 
sternum, ribs, intercostal spaces, shoulder, scapula, and more infre- 
quently even in the brachial plexus and pulmonary branches of the 
vagus, resembling that of angina pectoris (Traube) or even producing 
sympathetic pain (Mueller) in the arms and legs. The pain varies 
with change of position, depending on the localization of the ulcer, 
but there is always pain when the patient lies on the left side. 

In relation to eating, there is a difference of opinion. Sometimes 
the pain occurs two to ten minutes after eating, the old "wound pain," 
supposedly due to contact of food with the eroded nerves in the ulcer. 
Again, the pain occurs at the height of digestion, i.e., one-half to one 
and one-half hours after ingestion of food; this is caused by the hyper- 
acidity of the gastric juice. Patients fear to eat because of the inevit- 
able pain. Pain may occur after meals for months, and disappear 
to recur after months. (In some cases of ulcer there is constant 
flow of gastric juice [v. Hypersecretion] which may result in two 
kinds of pain, one of which is present when the stomach is empty and 
the other at the height of digestion.) Pain may be worst at the time 
of the menses. Pain from the scars or adhesions of an ulcer is infre- 



620 DISEASES OF THE DIGESTIVE TRACT 

quent, is rarely cramp-like but usually drawing or vague, and some- 
times continuous. In old ulcers pain is atypical or wholly absent. 
The time of development of the pain does not locate the ulcer, though 
if it comes on at once it may suggest oesophageal or cardiac ulcer; or, 
if it occurs two and a half hours or more after eating, it is suggestive 
of ulcer of the duodenum. 

Tenderness is most often found under the ensiform or near the navel 
(if there be gastroptosis). It is usually circumscribed and is more often 
and more advantageously found on the lightest touch, rather than on 
deep palpation. A diagnosis from tenderness alone is somewhat unsafe. 
Tenderness in the back (Cruveilhier) suggests ulcer on the posterior 
wall of the stomach and is found in 25 to 33 per cent, of cases over an 
area of one or two inches to the left of the tenth to twelfth dorsal or 
upper lumbar vertebrae. The abdomen, back, and chest, are often 
exquisitely hyper aesthetic. In a few cases pressure is grateful (Osier). 
Palpation must be guarded, for perforation has followed undue pres- 
sure. 

2. Hsematemesis. — The second cardinal symptom is haematemesis. 
Some authors consider it the most important and certain finding. 
Its frequency is variously given at from 25 to even 80 per cent.; the 
average figure is probably 50 per cent. Vomiting of blood in ulcer is 
most frequently from ulcer in the pyloric region (posterior wall and 
lesser curvature) , or, less frequently, from ulceration reaching the liver, 
pancreas, or spleen. Hemorrhage when small may be overlooked 
(occult hemorrhage), or blood may be found only in the stools; melaena 
alone is found in 11 per cent, of cases. It is said that the hemorrhage 
must amount to a pint to turn the stools black. It may be large and 
sometimes prove fatal; indeed it may be so acute that no blood is 
vomited and the stomach and bowels are found to be filled with one 
massive clot. The usual signs of internal hemorrhage exist, as collapse, 
pallor, moderate rise of temperature, brain anaemia, haemic mur- 
murs, amaurosis, and rarely, optic atrophy or hemiplegia. If profuse 
it is voided bright red; if slow and moderate the acid turns it dark, 
''coffee-grounds vomitus." If red blood cells cannot be found in the 
vomit because of complete disintegration of the cells, blood can be 
detected by treating it with acetic acid, extracting with ether and then 
testing with the guaiac and turpentine reaction, when blood will be 
shown (Bial) even if the spectroscope shows nothing. "Occult hemor- 
rhage" occurs in 25 to 50 per cent, of cases (see Haematemesis and 
Cancek) ; it is not as constantly present as in gastric cancer. J. Dutton 
Steele concludes that the tests for occult hemorrhage are valuable; 
first, to determine the length of the various periods of the medical 
treatment of ulcer. Second, to detect the tendency to bleeding during 
the course of gastric ulcer and by appropriate medical and surgical 
measures to anticipate and prevent serious hemorrhage. Third, to 
determine when the medical treatment may be considered to have 
failed and surgical treatment is indicated. Fourth, perhaps the test 
may prove helpful under certain circumstances in detecting the de- 



ROUND ULCER OF THE STOMACH 



621 



velopment of a cancer upon the floor of an ulcer. Blood is found 
macroscopically in the stomach washings less frequently than is to be 
inferred from text-book descriptions, and apparently normal vomitus 
may show blood microscopically or chemically. Profuse hemorrhage 
usually indicates deep ulceration. Hemorrhage is said to complicate 
chronic more than acute cases, though this does not correspond to 
personal experience. The hemorrhage is usually fairly profuse in 
ulcer; it may be spontaneous during sleep or rest or may result from 
excitement, physical exertion, or improper diet. In a case of " chronic 
dyspepsia" with vague symptoms, the writer inflated the stomach 
with the usual amount of carbon dioxide; the patient collapsed in the 
office and vomited nearly a quart of blood. 

3. Hyperacidity. — This is the third cardinal finding. Though it 
has often been stated to be a constant finding by Riegel and others, 
Hemmeter finds it in 90 per cent, and Leube in 50 per cent. : 



HCl according to 


Normal acidity. 


Hypo chlorhydria. 


Achlorhydria. 


Hyperchlorhydria. 


Ewald 


57% 
36% 
46% 


9% 
34% 
20% 


23% 
4% 


34% 


Eichhorst 


7% 




30%, 







The variance noted in these figures is due, in the author's opinion, to 
combining old callous ulcers with the fresh chlorotic ulcers; in old 
ulcers hyperchlorhydria is present in only 10 per cent., and they explain 
most of the cases of decreased acidity; in fresh ulcers, hyperacidity 
occurs in 70 per cent. Hyperchlorhydria is probably due to irritation 
of the vagus (Pawlow). Complicating cancer, hypersecretion or catarrh 
may cause subacidity. 

Should a test meal be given in cases of ulcer, to determine whether 
an excess of acid exists ? Certainly not, when the diagnosis is deter- 
mined by the pain, tenderness, and vomiting of blood, or when the 
ulcer lies at the cardiac end of the stomach. The stomach tube, how- 
ever, is used by Riegel, Boas, Rosenheim, Fleiner, and others, not only 
for diagnosis in atypical cases, but also to relieve the more dangerous 
vomiting and to introduce silver and bismuth into the stomach. Or- 
ganic acids, as lactic, are absent, the carbohydrates are poorly digested, 
and the albumins are rapidly converted into albumoses or peptones. 
The motility of the stomach is normal in one-quarter and slow in 
three-quarters of the cases. If pyloric obstruction exists the mineral 
acid is still more increased. 

4. Other Symptoms. — Vomiting, present in 75 per cent., is a less 
valuable diagnostic than pain, although they usually occur together. 
Some cases never vomit, or do so only several hours after meals. It 
occurs at the height of the pain, one, two or three hours after eating, 
whereas in dilatation or hypersecretion it occurs much later. Vomit- 
ing as well as pain depends directly on the diet, heavy meals increasing 
and appropriate diet lessening each. It may be uncontrollable. Some 
degree of parallelism exists between the pain and vomiting, the latter 



622 DISEASES OF THE DIGESTIVE TRACT 

usually relieving the former. The vomitus usually consists of fine 
particles, is sour, grits the teeth, and shows much acid and no fermen- 
tation. Dyspepsia occurs from catarrhal gastritis, dilatation, or other 
complications. The appetite is very frequently good or even exag- 
gerated. Acid eructations (pyrosis) may cause a burning sensation 
back of the sternum or between the shoulder blades. If there is much 
oesophageal burning it indicates incontinence of the cardiac orifice. 
Diarrhoea is rare. Constipation is due to the anaemia, diet, rest, 
vomiting, possibly reflex inhibition from the stomach upon the motor 
nerves of the bowel or to impairment of peristalsis by scars and adhe- 
sions. Dysmenorrhcea and amenorrhcea are not infrequent. Blood 
may be found in the stools. Fever is a complication. The nutrition 
varies and emaciation may be observed (cachectic type). Ansemia is 
more common in men and may become profound. The urinary 
findings are not characteristic. Reduction of the chlorides cannot be 
used to differentiate from carcinoma. The urine is slightly acid or 
even alkaline, particularly when the stomach is dilated. The phos- 
phates are increased; with dilatation, indican and ethereal sulphates 
are increased. Acetonuria and diaceturia sometimes result from inani- 
tion and from rectal feeding. 

Clinical Forms of Lebert. — (a) The hemorrhagic form may be either 
acute or chronic; hemorrhage may be the first symptom, or the last 
and fatal one. (b) In the perforative form there may be entire latency 
of previous symptoms, (c) In the dyspeptic type, dyspeptic symptoms 
are most prominent; the evidences of ulcer are absent, or there are 
atypical symptoms, such as pain, which is not sharp, vomiting, which 
is infrequent, and excess of hydrochloric acid ; but no increase in 
mucus, (d) The cachectic form is characterized by old ulcers, by 
cicatrix producing dilatation, and by chronic hypersecretion; this 
form may be confused with carcinoma, especially when there is no 
excess of acid. The other types are as follows : (e) gastralgic or neu- 
ralgic form; (/) vomitive form; (g) latent ulcer (scars at autopsy); 
(h) a form with tumor; (i) recurrent type; (j) stenotic type; (k) car- 
cinomatous type. 

Clinical Course. — The course is usually chronic, for ulceration is 
frequently long latent before diagnosis is possible, and probably lasts 
some time after all symptoms have disappeared. Pain usually indi- 
cates incomplete cicatrization or certain other sequences, but cessa- 
tion of pain is no certain criterion of healing. The course may be 
acute and rapid, especially under appropriate therapy. The course 
lasts from three to five years (Lebert) or even twenty to thirty-five 
years; this is usually due to such complications as pyloric obstruction, 
dilatation, or adhesions. Very large ulcers probably never heal. They 
frequently remit with appropriate therapy, but may recur with the 
resumption of the old diet. It is questionable when they can be con- 
sidered cured: certainly only when all symptoms have been absent 
for six months. 



ROUND ULCER OF THE STOMACH 623 

Localization. — This can rarely be determined accurately (Riegel 
and Leube). According to Gerhardt, tenderness and tumor are indic- 
ative of ulcer on the anterior wall, but hemorrhage and dorsal pain 
suggest posterior involvement. Pain in a lateral decubitus suggests 
localization in the fundus or pylorus; dilatation, in the pylorus or 
duodenum; pain under the ensiform during the act of deglutition 
suggests cardiac ulcer and contra-indicates the use of the sound. Ulcers 
are palpable in only 0.1 per cent, of cases (Leube). The percentage 
of involvement of the cardia is 6.3; of the fundus, 3.7; of the lesser 
curvature, 36.3; of the posterior wall, 29.6; of the pylorus, 12; of the 
anterior wall, 8.7. " In over 80 per cent, of the cases it occurs in a rela- 
tively small area about the pylorus, lesser curvature, and posterior wall." 

Complications and Sequelae. — (a) Perforation (6 per cent.) may 
occur into the peritoneum, usually with symptoms of collapse, peri- 
tonitis, and cessation of vomiting (Traube), though Brunner finds 
vomiting in 66 per cent, and Gross in 33 per cent, of such cases. 
Perforation may be prevented by the left lobe of the liver, pancreas, 
or spleen, or by omental, pericardial, and pleural adhesions. The 
danger of perforation in ulcer of the anterior wall is seven times as 
great as in that of other locations. Perforation of a latent ulcer may be 
confused with rupturing appendicitis or salpingitis. Perforation may 
occur into the heart, colon, gall-bladder, portal vein, pericardium, 
chest wall, or abdominal wall; or it may reach the space between the 
liver or spleen and the diaphragm, producing pneumothorax subphren- 
icus, which is suggested by pleurisy, epigastric and hypochondriac 
pain, stiffness in the back, painful eructations and swallowing, singul- 
tus, dorsal decubitus, or local oedema, (b) Simple peritonitis (perigas- 
tritis) may cause a friction murmur over the stomach, (c) According 
to Rosenheim 6 per cent., Liebert 9 per cent., or Zenger, the major- 
ity of cases of cancer develop from ulcer. Two years ago the author 
saw with Dr. Harpole a case of carcinoma developing in an ulcer scar 
in a girl twenty-six years old. The typical symptoms of ulcer are 
followed by loss of weight, and persistence of symptoms, usually by 
gradual lessening of hydrochloric acid and other evidences of car- 
cinoma, (d) Adhesions about the stomach may interfere with its 
motility, produce deformation, such as the hour-glass stomach or 
diverticulum, neuralgia which outlasts the ulcer, and obstruction of 
either orifice of the stomach. Dilatation of the stomach usually, but 
not always, indicates pyloric stenosis; it may also indicate cicatrizing 
ulcer or result from spasm of the pylorus. Scars may, in rare cases, 
produce intestinal obstruction. Troublesome adhesions may be finally 
so stretched as to relieve all symptoms. 

Diagnosis. — The diagnosis is determined by (a) the etiological 
factors, (6) the cardinal symptoms, and (c) the various clinical types 
enumerated. In general the diagnosis is easy in the young, but may 
be difficult in ansemic or chlorotic individuals. 

Any two of the cardinal features confirm the diagnosis. Pain is 
often the only symptom; if it is atypical, hyperacidity may indicate 



624 DISEASES OF THE DIGESTIVE TRACT 

ulcer, though the latter is often observed without ulcer; Leube pro- 
poses for such cases the therapeutic test, although both cases may 
respond to the treatment. According to Riegel the chief difference is 
that pain in simple acidity is less regular than in ulcer and that local- 
ized tenderness is absent, though he admits that these criteria may 
fail. Some cases of seemingly primary hyperchlorhydria are found to 
be ulcers. Where pain alone exists one must always remember the 
gastric crises of tabes. Ewald has called attention to the pain of small 
hernias in the linea alba. Pain may cause confusion when it occurs 
in the transverse colon, which lies in close apposition to the stomach, 
but it usually ceases on evacuation of the bowels. Without careful 
examination movable kidney may be confused with ulcer. The pain 
in gall-stones is paroxysmal, but more irregular, and is independent of 
eating. Icterus in gall-stones is not common. The gall-bladder is 
tender, and may be distended and palpable. The paroxysm in gall- 
stones is often attended by fever, which is not present in ulcer, and by 
a chill. The paroxysm is longer. The liver may be large, especially 
the right lobe. The pain more often radiates to the right side and 
to the shoulder, and the vomiting is not that of ulcer, though hyper- 
acidity and gastric dilatation may follow cholelithiasis. Chronic 
poisoning, as by arsenic, may be suspected, as in the case of the 
Duchess of Orleans until Littre made the diagnosis of ulcer. 

Hemorrhagic erosions and fissures of the stomach present no con- 
stant clinical picture. After eating there is a sense of burning over the 
entire stomach, which is not altered by change of position. The 
chemism and tender points of ulcer are lacking, though Cohnheim 
usually finds hyperchlorhydria; he also believes that solid food relieves 
the pain. Shreds of tissue are always found, according to Pariser, 
which cease with cessation of pain. Fatal hemorrhage is recorded. 

In duodenal ulcer (as in inflammation, new growths of the liver, 
perihepatitis, cysts, and chronic pancreatitis), hyperacidity is absent, 
although in some instances of duodenal ulceration hyperacidity has 
been observed. Duodenal ulcer occurs mostly in men, in alcoholics, 
and after burns. Pain is often absent in duodenal ulcer, but when 
present occurs later than in gastric ulcer and in the parasternal line. 
Vomiting gives less relief, and the vomitus is usually alkaline, contains 
bile, and may digest fibrin (Boas). Icterus is not uncommon, though 
not constant enough for diagnostic reliance. Hemorrhage into the 
bowels is more common than in ulcer. Its sudden appearance with 
recurrence and profound anaemia is most suggestive. 

Pyloric spasm, considered so characteristic of ulcer by most writers, 
may also occur in myocarditis, aneurysm, coronary atheroma, taenia, 
ascaris, the spastic form of intestinal constipation, or chronic nico- 
tinism (Ageron). 

Differentiation from carcinoma is not very often necessary, though 
in middle-aged patients confusion with ulcer may occur. In Kraus* 
clinic, the author saw two cases; one was an old man with cachexia, 
pyloric tumor, and decreased hydrochloric acid, which was diagnostic 



ROUND ULCER OF THE STOMACH 



625 



cated cancer; the other was a young girl with vomiting of blood, in 
whom the diagnosis of ulcer was made. The post-mortem examination 
showed that the old man had a round ulcer and the girl had a cancer, 
The author has seen five cases of carcinoma under the age of thirty, 
The table on page 626 considers differentiation from cancer, gastritis, 
gastralgia, and hyperchlorhydria. 

Prognosis. — Though ulcer occurs most frequently between the ages 
of twenty and forty, it is most fatal between forty and sixty. It is 
generally stated that the mortality ranges between 6 or 8 and 10 or 13 
per cent, of the cases, of which about 4 per cent, is due to hemor- 
rhage and 6 per cent, to perforation. Debove and Redmond give the 
high death-rate of 50 per cent. 





Recovery. 


Death. 


Improvement. 


No Improvement. 




85% 
74% 
61% 


8% „ 
2.4% 

6% 


4% 
22% 
30% 


3% 


Leube 

Kohler 


1.6% 

3% 



Very deep and old ulcers rarely heal. The deeper the ulcer the greater 
the danger of hemorrhage and perforation. Ulcers with coincident 
hypersecretion give a relatively poor prognosis. Carcinoma must be 
considered in cases which do not respond to treatment. One of the 
author's cases died from exhaustion, although the autopsy showed 
that there had been perfect healing of the ulcer. In over one thousand 
cases the deaths from hemorrhage and perforation (each 1 per cent.) 
are about equally divided (Leube). 

Treatment. — 1. Prophylaxis. — Prophylaxis concerns care of the 
stomach in ansemia, and chlorosis, and with a history of ulcer, care in 
the diet. The mouth should be kept clean to avoid parotitis. 

2. Absolute Rest. — Absolute rest in bed for a month or more was 
first recommended by Cruveilhier, in addition to which Leube recom- 
mends the frequent application of hot fomentations to the epigastrium, 
which relieve pain within a few days. Women should remain in bed 
during menstruation, even after recovery is seemingly complete. 

3. Absolute Rest of the Stomach. — Though opinions differ some- 
what, it is true that distention of the stomach by even small quantities 
of food or water excites peristalsis and secretion, distends the ulcer, 
and prevents granulation. Rest permits the stomach to contract and 
allows the edges of the ulcer to come more rapidly and completely in 
apposition. The more absolute the rest of the stomach the more rapidly 
the ulcer granulates and cicatrizes. The time for complete granu- 
lation varies with each case, and chronic ulcers show little or no ten- 
dency to cicatrize. An ice-bag promotes contraction of the stomach. 
Rectal feeding is imperative, and the usual rules should be followed; 
peptonized milk, grape sugar, baby foods, meat juice, and eggs, should 
be given, in amounts not to exceed a total of eight ounces, and at eight- 
hour intervals; they should be injected slowly, with the patient on 
his left side, and should be given warm, which precautions obviate 



40 



626 



DISEASES OF THE DIGESTIVE TRACT 





Cancer. 


Ulcer. 


Chronic 
Gastritis. 


GASTRALGIA. 


Hyperchlor- 

HYDRIA. 


Etiology. 


75% over 40 years. 


75% under 40 
years — 2-4 times 
oftenerin women. 


Males. 


Women. 


Males. 


Tongue. 
Appetite. 


Heavily coated. 
Usually anorexia. 


Usually clean 
and red. Good: 
only fears to eat. 


Gray- white fur. 
Poor. 


Normal. 

Variable. Some- 
times perverted. 


Clean. 

Good, often 

increased. 


Pyrosis. 


Often pyrosis. 


Water brash. 


Frequent. 


None. 


Present. 


Belching. 


Usually foetid 
belching. 


Usually absent. 


Copious. 


Variable. 


Usual. 


Pain. 


The pain is less in- 
tense, but more 
constant; seldom 
free intermissions, 
during which no 
distress is felt in 
gastric region. Pain 
not increased at 
the height of diges- 
tion. Tenderness 
less frequent and 
intense. 


Intense; appears 
shortly after 
meals; grows 
severer on pres- 
sure; disappears 
at the end of di- 
gestive period; 
perfectly free 
periods more fre- 
quent; paroxys- 
mal. 


May be present 
but not pro- 
nounced and 
rarely actual 
pain but ten- 
derness of dif- 
fuse charac- 
ter. Lancina- 
ting pains in 
atrophic gas- 
tritis only. 


The pain appears 
without regular- 
ity, and not de- 
pendent upon 
meals; may be 
relieved by pres- 
sure; intervals of 
several days free 
from pain. Ten- 
derness rare; con- 
forms to outlines 
of the stomach. 
Electrical test 
(Leube) during 
digestion; if pain 
decreases, it is 
gastralgia; if it 
does not, may be 
ulcer or gastral- 
gia. 


The pain ap- 
pears about 
one or three 
hours after 
meals, disap- 
pears after eat- 
ing, especially 
meat, milk or 
eggs, or after 
the administra- 
tion of bicar- 
bonate of so- 
dium. Pain is 
[ess regular. 


Vomiting. 


Usual. Hours after 
eating or once a 
day or alternate 
days, etc. Copious, 
coarse mucus, fer- 
mented. 


Frequent — at 
height of diges- 
tion — s mailer 
amount, finely, 
homogeneous, 
no mucus, acid. 


Frequent; mu- 
cus. 


Rare: no mucus. 


Much less fre- 
quent, then 
acid and no 
mucus. 


Hcema- 
temesis. 


Frequent — small, 
dark, like coffee 
grounds, decom- 
posed, usually late 
in disease. 


F r e q u e n t — co- 
pious, bright; 
may be early 
symptom. 


None. 


None. 


None. 


Test 
Meal. 


Early reduction 
HC1 and later, total 
absence; ferments 
decreased or ab- 
sent; lactic acid 
present; impaired 
motility and ab- 
sorption; abun- 
dant mucus, Op- 
pler-Boas bacillus. 
— ■ yeast — possibly 
tumor shreds; 
coarse undigested 
particles of food. 


Hyperchl o r- 
hydria often; fer- 
ments normal or 
increased; no 
lactic nor Oppler- 
Boas bacilli; food 
well digested. 
No mucus. 


Decreased HC1 
(rarely in- 
creased, gastri- 
tis acida); later 
may be achy- 
lia. 


Normal or vari- 
able. If HCl is 
decreased, the 
ferments are nor- 
mal. 


As in ulcer. 


Tumor. 


In 80 per cent. 


In but one pro 
mille (from py- 
loric spasm, hy- 
pertrophy, cica- 
trix, etc.) 


None. 


None. 


None (very 
rarely f r o"m 
pyloric spasm). 


Collateral 
Symptoms. 


Cachexia — oedema. 


Absent. 


Absent. 


Absent. 

Nervous s t i g- 
mata often. 


Absent. 


Course. 


Part of a year. 


Longer; helped 
by treatment — 
aggravated by 
arsenic. 


Chronic. 
— ditto. 


Arsenic helps. 


Like ulcer. 



ROUND ULCER OF THE STOMACH 627 

excessive peristalsis. A piston syringe should never be used ; a fountain 
syringe with a soft tube is always used. Nutrient rectal enemata can 
be retained almost invariably if the technique is carefully carried out. 
Wine or spirits almost always irritate the bowel. Rectal tenesmus 
is obviated by administering a short time before the enema, an opium 
suppository of one-half grain of the extract. Though rectal feeding 
gives the patient but one-quarter of the food necessary to maintain 
metabolism, it is sufficient, because the patient is absolutely quiet. 
Thirst should be relieved by allowing the patient to rinse his mouth 
out, but he should swallow nothing, either water or melted ice, and 
by giving two administrations daily of warm saline enemata. 

4. Pain. — Rest of the stomach relieves the pain in almost every 
case; the use of narcotics should be limited as much as possible; small 
doses of opium or morphine by rectum, or atropine, may be given. 
There is, of course, danger that the patient may develop the opium 
habit. 

5. Superacidity. — Though many physicians would begin the treat- 
ment of superacidity at once, the author is convinced it should be 
initiated ten days to two weeks after commencement of treatment, 
during which time the stomach has had absolute rest. Then Carlsbad 
water should be given; it should be lukewarm, because hot water 
opens the ulcer; it should be given in small quantities and taken in 
sips. It was formerly held that alkalies were incompatible with 
digestion, but Ziemssen, Leube, and others, have disproven this point. 
Carlsbad water consists of sodium sulphate 50 parts, sodium bicar- 
bonate 6 parts, and sodium chloride 3 parts; it possesses no intrinsic 
value other than its alkalinity; it neutralizes the acid, thereby tending 
to check the ulceration, to aid intestinal digestion, and to cleanse the 
stomach. Ziemssen administered half an ounce in a pint of water; 
this was taken in quarters every ten minutes, the last dose being given 
one-half hour before meals. Vichy water may be used. Roberts 
prescribed a lozenge composed of magnesium carbonate, grains 3 \\ 
chalk, grains 2\\ sodium chloride grain 1, which, dissolved slowly in the 
mouth, increased the salivary flow and neutralized the excess of acid. 

6. Diet. — After ten days of rectal feeding, five or six meals daily of 
predigested milk with lime water should be given in small quantities, 
that the edge of the ulcer may not be distended. The saccharate of 
lime is five times as rich in lime as is lime water. Cooked milk is more 
easily digested and curds less. The casein both engages and neutral- 
izes the acid. If peptonized milk is distasteful it may be administered 
as a thin gruel; this is especially indicated when the stomach is very 
irritable and painful. Potato puree, arrow-root, wheat-meal, baby 
foods, meat juice, and buttermilk, may be given; soups with meal and 
alkalies which precipitate the casein in finer form, Mosquera's beef 
meal, beef peptone jelly, and ice cream, may also be given ; but it should 
be remembered that the milk diet recommended by Cruveilhier is 
most efficacious. After the patient has been on the above mentioned 
diet for ten days, soups without fat, rice, sago, soft-boiled eggs, calves' 



628 DISEASES OF THE DIGESTIVE TRACT 

brains, and chicken, may be administered. Raw eggs are digested 
with difficulty, but slightly boiled or poached eggs are less indigestible 
and may be given with bread-crumbs from the inside of the loaf. 
Custards may be given. Tea and coffee should be forbidden. Sugar 
was considered deleterious bv Cruveilhier, but Strauss has found that 
it lessens the amount of acid and he recommends that the patient 
should have a dram of a 20 per cent, solution. After fifteen days 
Leube permits grated beef, and after about another week, tender 
roast beef, chicken, and pigeon, to which others would add lamb, mac- 
aroni, thymus gland, and bread. After the fifth week, roast veal and 
souffles may be given. Cohnheim gives olive-oil freely at all times; 
he finds that it relieves spasm and inhibits hyperchlorhydria. 

7. The Bowels. — Plain enemata may be administered after the first 
or second week. 

8. Drugs. — Much has been written in regard to the administration 
of bismuth and silver. Bismuth may relieve pain and is taken most 
advantageously in solution; the author does not believe that bismuth 
has any curative value; its use is less efficacious than absolute 
and prolonged rest of the stomach. Fleiner, Kussmaul, and others, 
administer bismuth by means of the stomach tube. The objections 
to large doses are that they may accumulate in the ulcer, the drug 
may cause pain, and is expensive. Chalk and talcum are no more 
efficacious than bismuth. Silver has been used, and some writers 
even wash the stomach of the patient before meals with a solution of 
1 to 500 or to 1,000 (Reichmann). The silver is readily precipitated 
by the acid or the albuminoids, and unless given in capsule or pill or 
by the stomach tube may produce nausea, burning in the mouth, 
diarrhoea, and even argyria. Iodide is indicated in syphilitics, by 
whom it is well tolerated. 

9. Symptomatic Treatment. — Pain is best relieved by rectal alimen- 
tation, as is vomiting, which sometimes may necessitate the adminis- 
tration of bismuth, minute doses of carbolic acid in mint water, or 
the use of the ice-bag or sinapisms. Hemorrhage is treated by absolute 
rest of the stomach, intestine, mind, and body; morphine quiets peri- 
stalsis and mental excitement. No styptics or astringents should be 
given and ergot is contra-indicated. Syncope promotes spontaneous 
coagulation, and stimulation should be avoided as long as possible. 
In severe hemorrhages the use of saline transfusions should be con- 
sidered, but more than one pint should seldom be given, for death has 
occurred from reaction and renewal of hemorrhage. Gelatine injec- 
tions may be indicated for severe hemorrhages. 

10. Surgical Treatment. — Seventy-five to 96 per cent, of cases, ac- 
cording to Leube, either heal absolutely or improve greatly under 
proper medical treatment; this is especially true of fresh ulcers. Leube 
in his widely quoted article gives the following indications for surgical 
interference: (a) When the hemorrhage is small and repeated, and 
persists in spite of rectal nutrition; in single large hemorrhages opera- 
tion is contra-indicated. Moynihan holds a similar view, and lost but 



CANCER OF THE STOMACH 629 

1 out of 70 cases of chronic hemorrhages, which result he attributes 
to his treating the ulcer instead of performing simple gastroenteros- 
tomy. Savariand estimates the operative mortality at 50 and Rodman 
at 33 per cent. Turner (1905) finds a mortality of 36 per cent. (56 
cases), (b) Gastroenterostomy is indicated for mechanical difficulties, 
pyloric obstruction, persistent pyloric spasm, and pain; obstruction at 
the cardia, or hour-glass stomach, also requires surgical treatment. 
Thirty-one cases of jejunal ulcer have followed operation, since Braun's 
first case; it develops usually after a year or more (ten days to seven 
years). Mickulicz in operations for benign gastric disease finds a 7.5 
per cent, mortality in his series of 1897-1899. Moynihan in 15 opera- 
tions for hour-glass stomach had a mortality of 20 per cent., and in 
100 cases of gastro-enterostomy a mortality of 2 per cent, (c) Peri- 
gastric adhesions or abscess, and collections of pus beneath the dia- 
phragm, necessitate operation, (d) In cases of perforation the outlook 
is fairly good if early operation is undertaken and is performed at 
once when the initial shock has passed. The best figures are those of 
English and Graff e with 50 per cent., of recoveries; of Ferrier and Hart- 
mann, with 47.5 per cent.; and, between 1900 and 1904, of H. A. Hare, 
with 37 per cent. Donati, of Florence, collected in 1905, 1,041 cases of 
operation on ulcer cases ; the mortality in perforation was 48 per cent. ; 
in gastro-enterostomy the mortality with the use of Murphy's button 
was 7.5 per cent.; with suture anastomosis, 14.5 per cent. 

Surgical interference is necessary in a limited number of cases. 
Sahli is opposed to excessive surgical interference, and argues that 
(i) reports only show that many of the patients stand an operation; 
(ii) gastro-enterostomy is indicated only for anatomical stenosis, too 
many cases of spasmodic stenosis are called anatomical, and at opera- 
tion too many contracted pylori are called cicatricial, (iii) Gastro- 
enterostomy is not proven beneficial for hemorrhage, diet being the 
important indication. Cases operated on often die from hemorrhage 
after the operation, (iv) No proof exists that ulcers heal better with 
gastro-enterostomy than with medical treatment, (v) Excision of the 
ulcer is too radical. The writer's experience justifies the conclusion 
that (i) fresh (chlorotic) ulcers always, and (ii) chronic ulcers in half the 
instances, belong to internal medicine; (iii) half the inveterate cases 
respond to medical treatment; (iv) most of the cases "chronic dyspep- 
sia," and almost none of the cases with hemorrhage, call for surgical 
interference. . 

(F). CANCER OF THE STOMACH. 

Cancer of the stomach is more frequent than cancer of any other 
organ; it constitutes 33 to 50 per cent, of all cancers, and is found in 

2 per cent, of autopsies. 

Etiology. — This is as obscure as in other carcinomata. (a) Age— 
75 to 80 per cent, of the cases occur in subjects after the fortieth 
year. According to Lebert 1 per cent, occurs in persons under thirty 



630 DISEASES OF THE DIGESTIVE TRACT 

years; 18 per cent, in those between thirty and forty; 61 per cent, 
in those between forty and sixty, and 20 per cent, in those over sixty 
years of age. Welch's figures give 2 per cent, under thirty, 13 per cent, 
between thirty and forty, 54 per cent, between forty and sixty, and 26 
per cent, over sixty years of age. Every clinician has observed a 
number of cases in persons under thirty years. The author has seen 
five, which leads him to believe that many more cases occur than is 
indicated by Debove's collection of 32 cases under the thirtieth year. 
Rare congenital cases are recorded (Wilkinson, Debove, Collings- 
worth). Of late years cancer is apparently becoming more frequent 
and more common in relatively young persons, (b) Sex — It is slightly 
more frequent in males (6 to 5). (c) Heredity is noted as an etiological 
factor in 6 to 17 per cent., and in some families the number of cases 
of carcinoma is astonishing, (d) Ulcer of the stomach is an antecedent 
in at least 6 per cent.; C. Graham found ulcer in 60 per cent, of his 
cases, (e) Other causes are less definite. Trauma, external pressure, 
as in shoemakers, or internal ulceration by caustics, is noted in some 
cases. Pulmonary tuberculosis and alcoholism are slightly predis- 
posing factors. Cancer is almost unknown in certain tropical and 
subtropical localities, and in temperate zones a topical disposition is 
occasionally apparent. 

Pathology. — (a) In origin it is an abnormal growth of the glandular 
epithelium, as was first proven by Waldeyer, which unlike mere adenom- 
atous or papillomatous proliferations, extends beyond the mucosa 
into the other coats of the stomach and very often into other organs 
and tissues. Cancer may develop in the seemingly normal mucosa, in 
an atrophied mucosa, or in open or cicatrized ulcers. (6) It is almost 
always primary, is very rarely metastatic, or extends to the stomach 
by contiguity; such secondary growths are usually from mammaiy 
or pancreatic cancer; Welch has collected 37 cases. It is also almost 
invariably single. 

Histology and Morphology.— A tumor, in the clinical sense, usually 
develops, although in some cases the cancer is infiltrative and flat 
{carcinoma planum). There are three main types: (a) Carcinoma 
fhrosum (scirrhus), the most frequent type, contains much poorly 
vascularized stroma and relatively little carcinomatous tissue; it is 
hard, and, leading to much induration, is prone to stenose the pylorus, 
where it is especially frequent, or to stenose the cardia; if it is diffuse 
it causes the stomach to shrink (carcinoma atrophicans) ; its onset is 
insidious; it grows slowly and ulcerates less than other types, (b) 
Carcinoma medullar e is next in frequency; the cell elements prepon- 
derate over the stroma; there is much soft, vascular tissue, and the 
knife scrapes out much "cancer juice"; it may form cauliflower-like 
exuberances; early extensive degeneration, ulceration, and metastases, 
are common; this type includes the cylindrical celled adenocarcin- 
oma, epithelioma, or the very vascular fungus forms, (c) Carcinoma 
gelatinosum (colloides) is least frequent; it produces nodular 
tumors or diffuse infiltrations, both of which contain colloid ma- 



CANCER OF THE STOMACH 631 

terial ; it inclines rather to extension by contiguity than to metastatic 
deposits. 

The gastric mucosa shows focal wasting of the peptic- and acid- 
secreting epithelium and substitution by cylindrical epithelium, round 
cells, and connective tissue. This secondary atrophic gastritis explains 
the chemism of gastric cancer — viz., diminution in the secretion of 
acid, rennet, and pepsin; in some cases it has regressed after surgical 
extirpation of the tumor, the secretion of acid and pepsin returning. 

Localization. — Cancer occurs (a) in the pylorus in about 60 per 
cent., (b) in the lesser curvature in nearly 20 per cent., and (c) in the 
cardia in 10 per cent, of the cases; in round numbers, therefore, about 
90 per cent, of cancer occurs in these sites; this is explained by their 
greater exposure to mechanical insult, their relative fixation, and the 
greater muscular activity of the pylorus and cardia; many tumors, 
apparently pyloric in origin, really begin in the lesser curvature, 
whence, in other words, a palpable pyloric tumor often means one of 
considerable extension; this is an important surgical point. 

Complications. — (a) Ulceration, which is really more a part than a 
complication of cancer, results from inadequate vascularization; it is 
usually central and does not necessarily depend on the size of the 
tumor. In some cases the tumor may ulcerate almost completely, and 
Ziegier has observed total disappearance, though metastases declared 
the nature of the scar. (b) Hemorrhage or slow seeping of blood is 
caused by ulceration, as is also (c) perforation (3 per cent.) into the 
peritoneum, or, by adhesions, into adjacent abdominal organs or vessels, 
into the lung, pleura, or pericardium, or into the abdominal wall, of 
which latter 22 cases are recorded; perforation is not more common 
because adhesions often prevent perforation, (d) Stenosis of the cardia 
or pylorus is common, sometimes causing hypertrophy of the muscle 
fibers, which appear on section of the stomach as red lines, (e) Dila- 
tation of the stomach follows pyloric obstruction, atrophy is observed 
in cardiac localization or in carcinoma atrophicans (diffuse cancer), and 
hour-glass deformation may result when an annular scirrhus develops 
in the mid-stomach. (/) Local extension by contiguity occurs by the 
submucous lymphatics, and there is early involvement of the lymph 
nodes along the lesser curvature; other lymphatics are soon invaded; 
the peritoneum is quite often involved, and less often there is exten- 
sion into the portal vein, (g) Metastases occur in 50 per cent.; they 
are distributed as follows: the liver is involved in 28 per cent., the 
peritoneum in 37 per cent., the lymphatics in 23 per cent., the pancreas 
in 20 per cent., and the lungs in 8 per cent. 

Symptoms. — General Clinical Picture. — Anorexia, distaste for meats, 
mild dyspepsia, gastric oppression, and eructations after eating, usually 
mark the insidious onset. Much less frequently the disease begins 
acutely or follows closely on symptoms of gastric ulcer. Vomiting 
occurs and then symptoms of gastric distress after eating solid food, 
and of mechanical or secretory insufficiency develop. There is gradual 
loss of weight together with loss of strength and endurance. Exami- 



632 f DISEASES OF THE DIGESTIVE TRACT 

nation reveals ansemia, cachexia, emaciation, lax skin, flabby muscles, 
and often a tumor near the pylorus. A test meal shows absence of free 
hydrochloric acid and imperfectly digested food. The symptoms pro- 
gress steadily, or remissions occur, especially early in the disease. The 
ankles become puffy and the prostration is profound. Ulceration may 
relieve pyloric or cardiac stenosis, but gradually within a year after 
the first marked symptoms death results, from the exhaustion due to 
pain or vomiting, from local complications, or intercurrent disease. 

1. General Digestive Symptoms. — (a) The tongue is almost always 
heavily coated, not being cleaned by mastication, and there is gen- 
erally a bad taste in the mouth. The appetite is decreased or absent 
in 85 per cent, and there is a special distaste for meat and fats; the 
appetite is very rarely excessive; a normal appetite may be retained 
when the motor power is good and cancer develops on an ulcer. (b) 
Pain is present in 90 per cent. It is usually diffuse, dull, oppressive, 
and less severe than in ulcer. It is increased several hours after eat- 
ing, or in the night, but is not wholly relieved by vomiting. Localized 
pain and tenderness are suggestive of circumscribed peritonitis. Pain 
may be reflected up the sternum, between the shoulders, and to the 
acromion, (c) Vomiting (in 85 per cent.) is an obstinate and rather 
advanced symptom, resulting chiefly from pyloric stenosis, with which 
it runs more or less parallel, and also from coincident gastritis. It 
appears late in the day or in the night, and may occur only on alternate 
days. There may be no vomiting in cancer of the curvatures, in diffuse 
cancerous infiltration involving the muscularis, or in pyloric cancer 
when ulceration is marked. The vomitus contains much mucus, 
poorly digested food, little or no free hydrochloric acid, much lactic 
acid, and often blood, which may be obvious or occult. Fsecal vomit- 
ing usually but not always indicates gastrocolic fistula (of which 70 
cases are recorded), (d) Hcematemesis, present in over 50 per cent, 
of cases, is due to parenchymatous oozing, and is therefore moderate 
in amount; it is dark in color, as the blood is retained long in the 
stomach and is converted from oxyhemoglobin to hsematin. It seldom 
reaches the stools because of pyloric stenosis. The author has seen 
four cases with fatal, profuse, bright hsematemesis. (e) Constipation 
is present in 75 per cent., diarrhoea in 20 per cent., and normal move- 
ments in 5 per cent, of the cases (Hemmeter) ; in two cases the writer 
has seen ichorous stools resulting from necrosis of the lower jejunum 
and of the ileum. 

2. Special Gastric Symptoms. — (a) Tumor is felt in 80 per cent, 
and seen in 40 per cent, of the cases, but is not an early symptom. It 
is most often missed in persons with a wide thorax and rigid abdom- 
inal muscles. In most instances it occupies the right epigastric area, 
as a round, ovoid, irregular mass; this is best determined when the 
knees are drawn up and the mouth is open, after the bowels have been 
flushed out and the stomach distended; in some cases the tumor may 
be felt lower or even on the left side. Examination should be made 
with the patient in several postures, as on the side, on the face, genu- 



CANCER OF THE STOMACH 633 

pectoral position, etc. Anaesthesia may facilitate detection. The 
tumor may be palpable one day and not to be found on the next, Dis- 
tention of the stomach by gas (von Frerichs) brings forward tumors of 
the anterior wall and greater curvature, obliterates tumors of the pos- 
terior wall and lesser curvature, and pushes downward and to the 
right tumors of the pylorus; motility on distention excludes adhesions. 
If the pylorus is incontinent from ulceration or infiltration, the gas 
escapes rapidly into the gut (Ebstein). The x-rays outline the stomach 
after administration of bismuth. With or without distention, a visible 
peristaltic wave suggests pyloric obstruction. Percussion is wholly 
subordinate to palpation and inspection, but auscultation occasionally 
elicits friction or a stenotic murmur over the abdominal aorta. Respir- 
atory excursion, though generally stated to be absent if the stomach 
is not adherent to the liver, is often present, though less in degree, 
than the excursion of the liver or spleen ; if adherent to the omentum, 
there is no excursion. The possibility of expiratory fixation is more 
important; if nonadherent tumors of the stomach, intestine, and 
omentum, are grasped at the height of inspiration, their ascent upward 
during expiration can be prevented (Minkowski's expiratory fixation) ; 
on the other hand, tumors of the liver and spleen, or tumors of the 
stomach, if adherent to the liver, must ascend during expiration; i.e., 
they cannot be retained where they were grasped and felt during 
inspiration, (b) Chemism — (i) Bird (1842) found the hydrochloric 
acid reduced, but Van der Velden (1879) showed the especial frequency 
of achlorhydria in gastric carcinoma. Absence or decrease of hydro- 
chloric acid is not pathognomonic, as it is also absent, permanently 
or temporarily, in numerous other conditions, as nervous dyspepsia, 
fevers, cardiac, renal or hepatic disease, pernicious anaemia, cachectic 
states, gastric atrophy, amyloid degeneration, and toxic gastritis. Ben- 
jamin Moore states that the hydrochloric acid is absent in 66 per cent, 
and decreased in 33 per cent, of carcinoma involving other organs than 
the stomach; the writer has repeatedly seen cases of rectal cancer in 
which digestive symptoms and achlorhydria have led to an erroneous 
diagnosis of gastric cancer. In cancer it is, as stated, due to the second- 
ary atrophic gastritis. After administration of an Ewald test breakfast 
of a slice of stale bread and a cup of weak tea without cream or sugar, 
the food is withdrawn in an hour and tested as described under chronic 
gastritis. If there is no stagnation the total acidity ranges from 6 to 8; 
in stagnation it is higher from lactic and other acids. The absence of 
free hydrochloric acid is often observed early, but is especially marked 
in the advanced stages. In very exceptional cases free acid may per- 
sist, both in those cases which develop from peptic ulcer and in those 
without this antecedent, (ii) The pepsin and rennet are decreased in 
66 per cent, of cases (v. Chronic Gastritis), (iii) Lactic acid, which 
is always pathological in appreciable quantities, is present in 70 to SO 
per cent, of cases, and though present in other conditions, as in atony, 
gastritis, and pyloric obstruction, 85 to 90 per cent, of the cases in 
which it is found are gastric cancer. Boas, who developed this topic, 



634 DISEASES OF THE DIGESTIVE TRACT 

considers it a very early rinding; while others, as Riegel, hold that it 
does not develop until later. The factors involved in its formation 
are somewhat disputed, but depend to a great degree on (a) the 
reduced hydrochloric acid; (/?) motor insufficiency, stagnation, 
pyloric obstruction; (y) slow absorption; in the normal stomach it 
is absorbed as fast as formed (Sticker) ; (8) probably also poor diges- 
tion of proteids. As a test meal Boas employs 1.5 per cent, oatmeal to 
100 parts of water; the UfMmann method is employed as modified 
by Strauss for phosphates, alcohol, and sugar also give the reaction; 
5 c.c. of the gastric filtrate are added to 25 c.c. of ether and shaken 
in a burette, which is provided with a cock at its lowest part; the 
lower 25 c.c. are drained away and 25 c.c. of distilled water are added 
to what remains (the etherial extract) in the burette. Two drops of a 
10 per cent, solution of ferric chloride and 20 c.c. of water are added; 
the blue solution turns to canary yellow if lactic acid is present, (c) 
Microscopically, the long, thread-like Ofpler-Boas bacilli (Plate XII) 
are found, which are probably one, though not the only, source of lactic 
acid formation; the bacilli stain brown with the Gram stain and are 
called Gram-positive. The}' may be confused with other morphologic- 
ally similar organisms, such as the Leptothrix buccalis, which however 
stains blue by Gram. The Oppler-Boas bacilli are also found in the 
faeces in gastric cancer; the bacilli point very strongly to the existence 
of gastric cancer, but may rarely occur, as in the writer's experience, in 
gastric ulcer and atrophic gastritis (with hypertrophy of the pyloric 
musculature). Small particles of tumor are seen in rare cases, showing 
carcinoma structure and irregular mitoses. Sarcinae are rarely ob- 
served. Occult hemorrhage (v. ELematemesis), i. e. } blood which can 
be seen only with the microscope or detected chemically or spectro- 
scopically, has the same significance as in gastric ulcer, (d) Motility — 
if the stomach is washed out four to six hours or more after eating, 
there are evidences of stagnation in the undigested food, particularly 
in pyloric localization; disturbed motility may appear very early in 
the disease. The stomach is usually much dilated in patients whose 
appetites persist and little dilated in those with anorexia. If the stom- 
ach is empty after six hours, good motility alone is proven, not good 
digestion. Every case of stagnation should arouse suspicion of car- 
cinoma. 

3. Other Symptoms and Complications. — (a) Cachexia results from 
malnutrition but is something more than malnutrition; it is probably 
the result of toxins which break down the proteids. The body weight 
is usually greatly reduced; in exceptional cases it may temporarily 
increase, as in cases of pyloric stenosis ; it may increase from hope, as 
in a case of Keen and Stewart, who gained 70 pounds after operation; 
or when the intestine digests what the stomach could not. The skin 
itches and is ancemic or clay-colored, somewhat resembling the tint 
it assumes in pernicious anaemia, though distinguished (i) by its later 
appearance, (ii) by its association with loss of weight, (iii) by the red 
cells being seldom lower than two million and the haemoglobin seldom 



PLATE XII. 




Oppler-Boas Bacillus in Vomitus. (Musser.) 



CANCER OF THE STOMACH 635 

below 40 per cent., though an apparently good count sometimes results 
from thickening of the blood which is due to lack of absorption ; and 
(iv) by the leukocytosis (see Pernicious Anaemia). Schneyer has 
described the absence of the digestive leukocytosis; it occurs in about 
half the cases. As in nephritis or chlorosis (rubra), the face may not 
show the real ansemia. The wrinkling and wasting of the hands may 
be far more significant, (b) The urine is decreased from poor absorp- 
tion and vomiting, the physiological change in the acidity-curve after 
eating is absent, the urea is increased from increased toxsemic catabo- 
lism, albuminuria is present in 35 per cent, of cases, and indicanuria 
is common, (c) Several toxemic symptoms may occur, (i) Fever 
of a low, irregular or intermittent type results from the cancer products, 
from septic absorption through the ulcer, or from complications as 
pleurisy or peritonitis, (ii) A coma closely resembling coma diabeticum 
may result from the cancer toxins or the breaking down of the proteids ; 
acetonuria has been noted, (hi) Phlebitis and the less common multiple 
neuritis, tetany, and amaurosis, are probably toxsemic. (d) Metas- 
tases or extension by contiguity may occur. Enlargement of the supra- 
clavicular glands may result from any abdominal carcinoma, but 50 
per cent, are due to cancer of the stomach (Troisier). Liver deposits 
may appear before any suggestive stomach symptoms. Icterus occurs 
in 5 per cent. (For other metastases v. Pathology.) (e) Ascites 
results (i) from the cachexia and, like the swelling of the ankles, appears 
late in the malady, (ii) Some cases are due to carcinomatous peri- 
tonitis, the fluid often showing blood and cancer cells, with mitoses, 
(Dock), and (hi) others result from glands or tumor compressing 
the porta hepatis. (/) Perforation (v. Pathology) may occur. 

Cancer of the cardia presents symptoms more like those of oesoph- 
ageal cancer (q.v.). The symptoms may be few or absent. The 
stomach is never distended. There may be tenderness under the 
xiphoid. The tumor when advanced may be palpated as well as the 
perigastric lymph nodes. 

Diagnosis. — Diagnosis is easy in the typical case outlined in the 
general clinical picture. No single finding, as achlorhydria, or even 
tumor, is pathognomonic ; only the grouping of symptoms and signs is 
final. Single analyses of the stomach contents are often deceptive; 
they should be repeated constantly and considered in connection with 
other findings. Vomiting in middle or advanced life is suspicious 
when accompanied by emaciation, ansemia, pruritus, and insomnia. 
With absence of hydrochloric acid and the ferments, the findings of 
tumor, blood, lactic acid, Oppler-Boas bacilli, dilated stomach, and per- 
haps of cancer tissue, are positive. The diagnosis may be doubtful, even 
in the presence of pyloric tumor, emaciation, and gastric dilatation, 
when hydrochloric acid is present; the tumor may then be peptic 
ulcer, hypertrophy of the pyloric musculature, or pyloric spasm due 
to hyperchlorhydria ; in the last instance the tumor is alternately 
hard and then soft, and often the chyme may be felt or heard as it 
intermittently squirts through the pylorus. The diagnosis between 



636 DISEASES OF THE DIGESTIVE TRACT 

beginning cancer, nervous dyspepsia and atrophic gastritis must be 
reserved for a time. Atrophic gastritis is more chronic, often lasting 
years without emaciation. Age is of no diagnostic value. Youth and 
adolescence do not exclude cancer; in the young, gastric cancer is 
more rapid in evolution, and hydrops and peritonitis are more com- 
mon. Ulcer (q. v.). 

The so-called latent, dyspeptic, gastralgic, anasarcous, ascitic, and 
anaemic forms of cancer, and those causing early metastases (for 
example, in the liver) and intestinal obstruction, show in what direc- 
tion error may occur, without due balancing of the individual and 
combined symptoms. 

Differentiation. — (a) Pancreatic tumors (q.v.) are deep, fixed, im- 
mobile, and disappear on gaseous inflation of the stomach. They 
may be accompanied by fatty stools, and by glycosuria. It must be 
recalled that the normal pancreas is sometimes palpable in meagre 
subjects, (b) Cancer of the gall-bladder has respiratory excursion but 
neither expiratory fixation nor lateral movement; the digestive symp- 
toms, chemism, ectasia, and changes on inflation, of gastric cancer are 
lacking, (c) Duodenal carcinoma is hard to separate, though the 
gastric chemism is usually lacking; passage of blood in the faeces, and 
icterus, are suggestive, (d) Cancer of the colon is usually distinguished 
by the presence of intestinal signs and the absence of stomach symp- 
toms or chemism. (e) Enlarged aortic glands are distinguished by 
lack of altered chemism, and abdominal aneurysm by absence of cancer 
chemism and presence of expansile pulsation; (/) omental and peri- 
toneal tumors are more diffuse, (g) Hypertrophy of the pyloric muscle 
(v. s.), felt as a tumor, is less common than is usually assumed; it is 
usually associated with the findings of ulcer or of hyperacidity; (h) 
foreign bodies (hair tumors), subserous lipoma, fibroma, myxoma, and 
other benign gastric tumors, and palpable round ulcers, are much 
rarer sources of error. Of sarcoma 59 cases are reported by Lecene 
and Petit; of these a dozen were successfully operated on. 

Prognosis. — The prognosis unhappily is determined by the diag- 
nosis, an error in which is the only hope. The average duration is one 
or two years (three months to three years). Death results from exhaus- 
tion by pain or vomiting, hemorrhage, gangrene, perforation, portal 
pressure, intercurrent pneumonia, nephritis, and tuberculosis. 

Treatment. — 1. Medical or Palliative. — (a) Condurango bark 
(Friedreich) seems for a time to increase the appetite and strength. 
(6) Vomiting is treated as in gastritis, dilatation, and simple ulcer, but 
with less success; lavage is indicated in pyloric stenosis; boric or 
salicylic acid or resorcin may be added for fermentation; narcotics 
by rectum, rectal feeding, champagne, and carbolic acid, as outlined 
before, are also useful, (c) Hemorrhage is rarely profuse and usually 
subsides on rectal feeding; iron, ergot, and lead, should be avoided. 
id) The achylia is seldom helped by hydrochloric acid or pepsin. 
(e) Pain necessitates the use of fomentations, lavage, chloroform (3 
to 5 drops) with ice, and as a last resort atropine or opium by rectum. 



H^MATEMESIS 637 

(/) For constipation, cathartics are inferior to warm colonic flushings 
or salts, glycerine or olive oil by rectum, (g) Diarrhoea is lessened by 
lavage; when due to pyloric insufficiency, salol, beta-naphthol ( aa gr. 
x) and opiates are indicated, (h) Stenosis of the cardia may yield to 
dilatation, (i) Motor insufficiency, evidenced by food in the stomach 
from five to seven hours after a test meal, necessitates lavage, which 
should be practised before supper, (jf) The diet should be soft and 
small in bulk. Meats and fats are digested with difficulty. Vegetables, 
cereals, small quantities of milk, koumyss, honey, pastries (not too 
rich), tea, coffee, diluted wine, peptones, albuminoses, baby foods, 
somatose, and nutrose, may be tolerated, but the stomach finally rebels 
at all food. 

2. Surgical or Radical Treatment. — Cases having good surgical 
prospects are few, but operation only can cure. When a tumor is 
found it usually has a rather wide extension; pyloric tumors, for in- 
stance, have often reached the pylorus from the lesser curvature 
(Israel). For resection of the cancer the cases should reach the 
surgeon, if possible, before the tumor is palpable, a condition possible 
only in private practice, for hospital cases are always advanced. 
Metastases, peritonitis and [glandular invasion are contra-indications 
to operation. Pylorectomy results in an immediate mortality of 15.6 
per cent, as against the original death rate of 56 per cent, in the time 
of Billroth, who did the first operation (1878). The ultimate outlook 
is very doubtful, recurrence having been noted after five years. The 
Mayos, in 1906, reported 100 resections of gastric cancer, with a mor- 
tality of 14 per cent.; in one group of 25 cases only one case died; 
27.7 per cent, of their cases were living three years after operation, and 
22 per cent, were well over three years after resection. The Mayo 
brothers logically plead for an early diagnosis (by exploratory laparot- 
omy) and for early resection. Gastrostomy is indicated in cardiac 
cancer, and g astro-enter ostomy for pyloric obstruction. 



(G). HAiMATEMESIS. 

Definition. — Hsematemesis is not absolutely synonymous with gastric 
hemorrhage; it is the vomiting of blood, which may come directly 
from the stomach or may reach it from the gums, nose, larynx, lungs, 
oesophagus, or even regurgitate backward from the intestine. Gastror- 
rhagia designates profuse hemorrhage from the stomach. It may be 
arterial, venous, or capillary. 

Etiology. — (a) Various forms of ulceration, as simple ulcer, carci- 
nomatous, tuberculous (of which Letorey [1895] found only 21 cases), 
diphtheritic, typhoid, syphilitic, ursemic, or phlegmonous ulcers, hemor- 
rhagic erosions, and perforations into the stomach from without, as 
gall-stones, or aneurysm dissecting down from the arch of the aorta 
(Minkowski), are etiological factors. Parrot described superficial ulcers 
in the gastritis of the new-born. Dieulafoy describes a pneumococcic 



638 DISEASES OF THE DIGESTIVE TRACT 

hemorrhagic gastritis. Chiari and Murchison, but especially Dieulafoy, 
have described very small simple ulcers causing profuse, often repeated 
and fatal hemorrhage; their diagnosis seems probable when they de- 
velop in perfect health and with no previous stomach symptoms; they 
are easily overlooked at operation or autopsy because they involve 
only the mucosa or perhaps some of the muscularis; some regard this 
form as the beginning of round ulcer, (b) Trauma, such as external 
violence, or internal trauma, as from foreign bodies, thermal and 
chemical injury, and violent vomiting, as sea-sickness and hyper- 
emesis, may be causal, (c) The cause may be vascular, such as 
amyloid degeneration which may sometimes involve the stomach and 
bowels alone; large or miliary aneurysm, arterial hyperemia, embolism, 
vicarious congestion from suppression of hemorrhoids or menstruation, 
passive congestion of cardiac or hepatic origin ; and oesophageal varix, 
though it should be remembered that when due to cirrhosis of the 
liver there is* in 33 per cent, of cases no other evidence of cirrhosis; 
Welch and Powell have found varices in the floor of peptic ulcers; 
malarial deposits in the liver; acute pylethrombosis, causing profuse 
hemorrhage; and parenchymatous oozing, where no postmortem, 
changes are found, (d) Nervous causes are injuries to the central 
nervous system, vasomotor influences, and hysteria (aside from simu- 
lation and artifices), in which the blood is small in amount and occurs 
usually in the morning vomit; tabetic crises; and general paralysis. 
(e) Acute injections may be etiological factors, as malaria, hemorrhagic 
exanthemata, yellow fever, sepsis, embolism after operations (von 
Eiselsberg), appendicitis (Dieulafoy), and genito-urinary sepsis (Guyon); 
Busse (1905) collected 96 cases following operations; they result from 
direct embolism (of which 35 per cent, are in the mesentery or omen- 
tum) or retrograde embolism; the hemorrhage occurred in the stomach 
or bowels; 55 per cent. die. (/) Blood diseases, as pernicious anaemia, 
leukaemia, haemophilia, purpura, scurvy, and splenic anaemia, may 
be causal, (g) Poisons, which early erode and later ulcerate, as acids 
and caustics, those causing fatty degeneration of the vessels as arsenic 
and phosphorus, and uraemia or cholaemia, may cause haematemesis. 

Most cases occur in women between fifteen and forty years of age. 
Of all causes, round ulcer and liver cirrhosis are the first to suggest 
themselves. At autopsy it may be impossible to find the point of issue 
of blood. 

Symptoms. — The symptoms are (a) those of the antecedent disease. 
(b) In some cases no blood may be vomited up, and the incident then 
remains undiscovered, unless the stools are examined. In vomitus 
cruentus gastric uneasiness is common. The amount vomited varies 
from microscopic quantities to those sufficiently large to cause death. 
The occurrence of "occult hemorrhage" has been particularly em- 
phasized by Boas; blood can be detected microscopically or chemically 
when not visible to the eye, in over 25 per cent, of the cases of ulcer 
and cancer; in microscopic examination the diet for days previously 
should contain no meat, blood, iron, or chlorophyll, but should consist 



SECRETORY NEUROSES OF THE STOMACH 639 

solely of eggs, fruit, flour, or fat. In profuse gastrorrhagia the blood 
is bright red, if it remains in the stomach only a short while, as it does 
in most cases of peptic ulcer. In smaller hemorrhages it is black or 
rust-colored, as in cancer, uraturia, cholsemia, various poisonings, and 
perhaps in peptic ulcer from action of the hydrochloric acid; rust- 
colored blood may become bright on the edges or surface when it has 
stood for some time. Blood may issue in the fluid form, or as clots, 
in which case it is suggestive of valvular disease, vascular diseases or 
the dangerous hsematemesis which occurs in cirrhosis. In a fatal 
•typhoid hemorrhage, which occurred in one of the author's students, 
enormous clots were vomited; the author has seen large clots vomited 
by patients having carcinoma of the stomach, (c) Melcena may 
render the stools black, tarry, and offensive, (d) Systemic signs may 
occur. A gradual or sudden intense ancemiq may be noted, with all 
the usual signs of ansemia (q.v.), with vertigo, syncope, tinnitus, 
spots before the eyes, rapid heart action, and some dyspnoea. Later 
there may be amaurosis, slight febrile movements, dicrotic pulse, 
hsemic murmurs, moderate oedema about the ankles, albuminuria, and 
sometimes hemiplegia or convulsions. 

Diagnosis. — Differentiation from haemoptysis (q.v.), from the swal- 
lowing of blood from the nipples in nurslings or from the vagina in 
the new-born, from fracture of the skull, from oesophageal or throat 
disease, and from simulation of blood in the stools from ingestion of 
bismuth, coffee, tea, claret, iron, or blueberries, does not need par- 
ticular elaboration, as the microscopic, chemical and spectroscopic 
examination determines doubtful cases. Weber's test for blood is 
made by adding to 15 c.c. of the vomitus or faeces, 5 c.c. of glacial 
acetic acid, and agitating with 20 c.c. of ether; the ether becomes 
brownish-red in the presence of blood, the brown acetate of hsematin 
being formed. Treatment is identical with that of the hsematemesis 
which occurs in round ulcer. 



(H). NEUROSES OF THE STOMACH. 

The neuroses of the stomach occur in nervous individuals, either as 
a part of a neurosis or as a rather isolated nervous symptom. Their 
relations will also be considered under neurasthenia and hysteria. 
They sometimes occur reflexly, as in gall or renal stones, or in uterine 
disease. Though their varieties will be considered as (I) secretory, 
(II) motor, and (III) sensory, combinations of symptoms are more 
frequent than single symptoms. 



(I). SECRETORY NEUROSES. 

These have been described especially by Reichmann, Rossbach, 
Sahli, and Riegel. 



640 DISEASES OF THE DIGESTIVE TRACT 

1. Hyperchlorhydria (Hyperaciditas Hydrochlorica). — This is a 
qualitative anomaly of gastric secretion in which the free hydrochloric 
acid is increased; it is not solely a neurosis, though conveniently 
classified as such; it is attended by no known anatomical lesion ; it is an 
excessive secretion of hydrochloric acid during the height of digestion. 

Etiology. — -(a) General etiological factors are as follows: (i) It is 
most frequent in young and middle-aged persons; (ii) in the better 
situated classes, (iii) in Polish Jews, and (iv) in brain-workers; (v) 
it is somewhat more common in women than in men; (vi) a neurotic 
or psychopathic tendency is a predisposing factor, as is also (vii) 
chlorosis, in which hyperchlorhydria is found in 85 to 95 per cent, of 
cases, (b) Local causes are (i) rapid eating and cold drinks; (ii) condi- 
ments; (iii) smoking; (iv) certain foods and coffee; (v) gall-stones, 
or possibly renal stones, which induce hyperchlorhydria by irritating 
the stomach; and (vi) habitual constipation. 

Symptoms. — Symptoms are quite often absent. The clinical picture 
varies much, and no single symptom is pathognomonic, (a) Pain 
is the chief symptom; it varies from a sense of pressure or discomfort 
in mild cases to extreme gastralgia in severe cases. It develops at the 
height of gastric digestion — i.e., one to two hours after eating— and is 
due to the excess of free hydrochloric acid; it depends on the kind 
and amount of food ingested; the more food, especially meat, ingested, 
the later is the pain, for the food engages the free acid longer. Carbo- 
hydrates cause increased pain, as they do not engage the acid, and 
amylolysis is decreased, perhaps suspended; in exceptional cases the 
patient tolerates small and frequent meals better than larger ones. The 
patient is often aware of the increased peristalsis and feels a cramping 
or spasm of the pylorus. Pain lasts one-half to several hours. It is 
relieved by vomiting, and unless it has become quite severe is also 
relieved by ingestion of more food or of alkalies. (6) Belching and 
pyrosis are frequent, and the eructated hyperacid fluid causes a burn- 
ing in the oesophagus — i.e., along the spine, (c) Vomiting of a sour 
fluid, which causes a burning sensation, is not frequent, save in severe 
cases, (d) The appetite is usually good, and most patients desire 
food frequently, though in small amounts ; occasionally it is ravenous. 
(e) Tenderness over the stomach is usually diffuse, moderate in degree 
and coincident with the pain; it is sometimes pyloric, and is associated 
with some epigastric distention. (/) Stomach tests show that the total 
acidity is increased to 100, even to 150 or 160; the digestive power is 
shown to be increased by the egg-disk test, the proteids are well sub- 
divided, the amylolysis delayed, motility and absorption normal or 
increased in uncomplicated cases, and no lactic acid, no fermentation 
and no gas are present, (g) Other symptoms are as follows: The 
bowels are irregular, constipation being more frequent than diarrhoea; 
headache is common, and migraine or neurasthenic symptoms may 
develop; the gums may retract (Herter); in the urine the chlorides 
are decreased, the acidity lessened during digestion, and frequently 
an alkaline reaction and phosphaturia are present. 



SECRETORY NEUROSES OF THE STOMACH 641 

Diagnosis. — The diagnosis is determined by the presence of hyper- 
chlorhydria in the vomitus and in the test meal, by the relief of the 
chemical pain by vomiting or ingestion of more food or alkalies, and 
by negative physical findings. 

Differentiation. — (a) Ulcer (q.v. table) is marked by well-localized 
tenderness and haematemesis or occult bleeding, and its symptoms are 
much more regular than in hyperchlorhydria, in which bleeding 
rarely results from erosions, (b) Gastritis is characterized by mucus 
formation and decreased secretion, save in gastritis acida, in which 
the hydrochloric acid rarely exceeds 50. (c) Gastrosuccorrhcea or 
continuous secretion (v.i.). id) Gastr ectasia and gastroptosis are ex- 
cluded by percussion and by inflation, (e) Gall-stones, in which pain 
has no relation to eating, occur at longer irregular intervals and are 
associated with turgidity and tenderness of the gall-bladder. 

Course and Prognosis. — The disease begins slowly and may dis- 
appear, to recur after a few days, weeks, or months, from irregular 
living, nervous strain, excesses, certain articles of diet, or sometimes 
without obvious cause. The nutrition is usually fairly well maintained. 
The outlook is generally good if early treatment is instituted ; compli- 
cations, as continuous secretion, gall-stones, or gastric atony, modify 
the prognosis. 

Treatment. — 1. Pkophylaxis. — Nervous factors, smoking, haste in 
eating, chlorosis, etc., should receive appropriate treatment. 

2. Diet. — (a) A proteid diet is most beneficial, for it takes up the 
largest amount of hydrochloric acid, which is not essentially increased 
by proteids, as has been maintained; veal, beefsteak, mutton, and 
ham, absorb twice as much hydrochloric acid as equal weights of other 
proteids (Fleischer); fish fat is particularly to be avoided; milk and 
some kinds of cheese may be given, (b) Carbohydrates should be 
restricted, because the early amylolytic gastric digestion by the ptyalin 
is delayed or arrested; a slice or two of stale bread, biscuits, toast, and 
zwieback, or purees of aleuronat meal, which contains much nitrog- 
enous matter, may be given; Strauss allows six to nine ounces of 
2 per cent, grape sugar solution, unless there is a complicating motor 
insufficiency. Potatoes, salads, and most uncooked vegetables, should 
be interdicted, (c) Fats may be given in limited quantities, including 
small amounts of cream or unsalted butter (one ounce); one or two 
drams of olive oil an hour after meals inhibit the secretion of acid. 
(d) Condiments, such as mustard, pepper, vinegar, spices, horseradish, 
coffee, alcohol, cold foods and drinks, should be forbidden because of 
their irritating action. Weak tea, cocoa or milk may be given, (e) 
Thorough mastication must be insisted upon. (/) Small meals, given 
at frequent intervals, are generally most efficacious, though Bouveret's 
three meals may sometimes be given if the patient's appetite is good. 

3. Medication. — (a) Alkalies, as sodium bicarbonate and mag- 
nesia usta, aa gr. xv to xxx, should be given at the height of digestion, 
to neutralize the hyperchlorhydria and relieve its symptoms; Pawlow 
maintains that alkalies do not only act chemically but inhibit secretion 

41 



642 DISEASES OF THE DIGESTIVE TRACT 

by action on the glandular cells. The charged alkaline waters dilute 
the gastric juice, neutralize the acidity, and are sedative, (b) Extract 
of belladonna, \ to J grain, given at meal-time, lessens secretion and 
mitigates pain; opiates are seldom indicated and should be avoided. 
(c) Lavage with silver nitrate (1 to 1,000) solution is useful in obsti- 
nate cases. 

2. Gastrosuccorrhoea (Hypersecretion, Parasecretion, Continuous 
Secretion). — This is a quantitative perversion of gastric secretion, in 
which a fairly abundant secretion is found in the fasting stomach; 
i.e., it occurs without the stimulus of food, and when the stomach 
should be empty. In the lightest forms it only occurs when food is 
ingested (alimentary form); in the severest forms it occurs without 
ingestion of food. It is not denied that some gastric juice may be 
found in the normal stomach, due to secretion initiated by swallowed 
saliva or mucus, but if this exceeds one-half to one ounce it is rarely 
physiological. Two forms are distinguished, the continuous (Reich- 
mann, 1882) and the intermittent form (Sahli, 1885). (a) The inter- 
mittent form occurs in attacks which last a day or two, is often called 
acute or nervous dyspepsia, and is found in about the same class of 
patients in which hyperchlorhydria develops; it has been observed 
during tabetic crises. Colic-like pain develops, usually at night, 
followed by sour eructations and repeated vomiting, first of food, then 
of three ounces or more of yellow-green fluid which contains hydro- 
chloric acid and ferments. The first vomitus may contain considerable 
hydrochloric acid and no more mucus than the small amount which 
the normal stomach contains; there is seldom blood. During the 
attack the pulse is small and rapid, the skin clammy, the urine scanty 
and alkaline, and headache is frequent. Thirst is great and drinking 
may give temporary relief, but is followed by increased vomiting. 
Between attacks the acidity is normal, and the appetite and general 
health are usually good; occasionally there is a constant sense of 
gastric discomfort, (b) The second form is continuous gastrosuccor- 
rhoea. Its etiology is similar to that of hyperchlorhydria (with which 
it may co-exist), but rather less clearly established. 

Symptoms. — (a) Pain is more marked than in hyperchlorhydria, 
develops later after eating, and very often at night (11 p. m. to 2 a. m.); 
it may occur before meals, for the gastric secretion is constant, or in 
severe cases it may be present both during the day and night; it is 
relieved by eating and by vomiting. There may be some local or 
diffuse tenderness, (b) Vomiting closely follows the pain, and may 
occur at its height, or during the night; the quantity of the vomitus 
varies; it is large when there is dilatation (a frequent complication 
and a common cause of this type). It contains hydrochloric acid, 
ferments, and a small quantity of mucus; vomiting may be absent in 
light cases, (c) There may be other digestive symptoms. The condition 
of the tongue varies, being often red and clean, but sometimes coated. 
The teeth are often carious. The appetite is usually good, sometimes 
ravenous, or in advanced cases may be poor. The thirst is marked, 



SECRETORY NEUROSES OF THE STOMACH 643 

and is sometimes suggestive of diabetes. The bowels are sluggish. 

(d) The results of the test meal and lavage show that the total acidity 
ranges up to 90 or 100, and free hydrochloric acid to 50 or 60. After 
a test dinner, the fluid, when removed, separates into three layers; 
the upper one is foamy, the middle one consists of yellowish fluid, and 
the lower one of sediment of fine undigested carbohydrates; the pro- 
teids are found to have been converted into peptones. When the 
stomach is washed out thoroughly at night to remove all fluid and 
food, examination on the next morning, of the fasting stomach reveals 
one to ten ounces of gastric juice (hydrochloric acid and ferments) — 
i.e., secretion without the stimulus of food; if the fasting stomach is 
washed out one, two or three hours later, gastric juice is again found — 
i.e.,\ihere is continuous secretion, when the stomach should be empty. 

(e) Other symptoms. The urine is the same as in hyperchlorhydria. 
Old cases show marked emaciation which may resemble cachexia, 
particularly because of the frequently lax muscles and dry, inelastic 
skin. 

Course and Prognosis. — The onset is slow and the course is pro- 
tracted; it may last for years. The nutrition suffers and death from 
exhaustion may result in untreated cases. Complications are frequent, 
especially (a) dilatation (atony, motor insufficiency), for the stomach 
is never empty; the hydrochloric acid does not inhibit the growth of 
sarcinse or yeast, and gases may generate. The dilatation may be 
primary but is most often secondary; it is differentiated by thoroughly 
washing out the stomach at night, and when the tube is introduced 
the next morning it should show nothing in simple dilatation. Dilata- 
tion may also result from (b) pyloric spasm. Pawlow has shown that 
in health the pylorus relaxes intermittently and allows the acid chyme 
to reach the duodenum; the pylorus is reflexly contracted by the acid 
fluid in the duodenum until this is neutralized, when the pylorus again 
relaxes. When the secretion is continuous, the passage of acid fluid 
into the duodenum constantly contracts the pylorus (hypertonic spasm) 
which sometimes may be felt as a tumor. In this case cancer may be 
suggested, especially when there is emaciation, or blood in the stomach, 
until the constant flow of gastric ferments and hydrochloric acid is 
found, (c) There is some tendency toward gastric ulcer, (d) Tetany 
is a rare complication of pyloric obstruction. 

Diagnosis. — The diagnostic features are (a) the pain at night; (b) 
vomiting, and (c) thirst, both of which are more common than in 
hyperchlorhydria; id) continuous secretion after washing out the 
stomach and during fasting. 

Treatment. — Treatment is in general (a) that of hyperchlorhydria 
as to prophylaxis, diet, mastication, and stimulants. (6) Rectal feeding 
is a valuable accessory; water, too, may be given by rectum to quench 
the raging thirst, (c) Oral feeding is allowed at long intervals; 
overloading of the stomach with fluids is carefully to be avoided, (d) 
Lavage relieves pain and hypersecretion. Reichmann employs irri- 
gation with silver nitrate (1 to 500 or 1,000). (e) Olive oil lessens 



644 DISEASES OF THE DIGESTIVE TRACT 

hyperchlorhydria (Riegel). (/) Alkalies and belladonna are indicated 
as in hyperchlorhydria. (g) Treatment of coincident dilatation; mas- 
sage or gastroenterostomy (which, however, is only indicated by pyloric 
obstruction, never for hypersecretion per se), may be indicated. 

3. Hyposecretion. — Hypacidity (hypochlorhydria or subacidity) and 
an acidity (achlorhydria) refer respectively to reduction or absence of 
hydrochloric acid, which may occur from nervous as well as from 
organic causes (see Gastritis; Achtlia). When the ferments and 
hydrochloric acid are absent, achylia gastrica nervosa is a more appro- 
priate term; the condition may be transient or enduring, and Einhorn 
reported a case in which secretion returned after an absence of five 
years. Suppressed secretion may occur in hysteria, tabetic crises, or, 
less often, in other affections of the cord. 



n. Motor Neuroses of the Stomach. 

These may be irritative (increased motility) or depressive (decreased 
motility). 

1. Irritative Types. — (a) Hyperkinesia or hypermotility hurries the 
food into the intestine, so that it disappears in three to five hours or 
even less. It exists by itself as a neurosis, but may occur in the hasty 
digestion caused by hyperchlorhydria, and in gastric atrophy, appar- 
ently in order that the intestines may earlier digest the unaltered 
food, (b) Peristaltic unrest (Kussmaul) or tormina ventriculi nervosa 
occurs in functional affections, particularly neurasthenia, and in or- 
ganic pyloric stenosis. In some cases the unrest may be wholly sub- 
jective, the patient experiencing a rolling or cramping sensation. In 
others, both neurotic and organic, the peristaltic movements from left 
to right may be seen, as well as antiperistalsis in the opposite direc- 
tion. The treatment of hyperkinesis and peristaltic unrest is that of 
the underlying neurasthenia and hysteria, (c) Pyloric spasm occurs 
very frequently as a secondary disorder, but very seldom, if ever, as an 
independent neurosis; it occurs usually in connection with ulcer, hyper- 
acidity, hypersecretion, fissures, erosions, chronic stenosing gastritis, 
sometimes with cancer of the stomach, and with poor mastication of 
food and drinking of cold fluids. Its relation to dilatation has been 
discussed, (d) Spasm of the cardia occurs in organic disease of the 
oesophagus and stomach (ulcer, cancer, erosions, hyperchlorhydria), or 
in neuroses; it is the cause of idiopathic dilatation of the oesophagus 
(q.v.), and the spasm in tetanus and hydrophobia. It makes vomiting 
difficult and is differentiated from organic stricture by the fact that 
in cardiospasm a large sound passes more easily than a small one, and 
that spasm is often — not always — intermittent. The treatment of 
pyloric spasm is that of the cause (almost invariably gastric) ; the 
treatment of cardiospasm is discussed under idiopathic oesophageal dil- 
atation, (e) Nervous eructations (Bouveret, Mathieu,Follet, Stern) occur 
in various neuroses and psychoses. They are said to occur especially in 



MOTOR NEUROSES OF THE STOMACH 645 

sexual neuroses. The odorless ructus does not result from fermentation, 
but from swallowing of air (aerophagia), which constitutes a most intrac- 
table habit. The mechanism by which air is swallowed is disputed; 
Bouveret correctly thinks it is forced down by pharyngeal contractions, 
but Oser holds that the stomach aspirates air. It is often swallowed 
unconsciously, or, again, it enters during what Matthieu terms false 
eructations, in which the patient, in attempting to raise gas, swallows 
air. The ructus can be caused only by aerophagia, as such large 
quantities could never generate in the stomach; Bardet estimated 
that one patient raised twenty quarts in an afternoon. Coincident 
cardiac and pyloric spasm causes distention (pneumatosis). Treat- 
ment lies in the use of the sound, suggestive therapy, and in the diffi- 
cult task of breaking the habit. (/) Nervous vomiting occurs (i) only 
in the neuroses, as hysteria, neurasthenia, migraine, and exophthalmic 
goitre; but under this caption we may also bring for differential purposes 
(ii) cerebrospinal conditions, as anaemia of the brain, compression, 
meningitis, tumor, tabes, general paralysis, disseminated sclerosis and 
myelitis; toxic conditions, as uraemia or cholsemia, may cause cerebral 
vomiting, (iii) Most cases sue reflex in origin; they may originate in 
the nose, as nausea from disagreeable odors; in the respiratory tract; 
in pelvic or abdominal conditions, as pregnancy, menstruation, gall- 
stones, renal calculi, and peritonitis. The symptoms may present 
many incompatible elements; thus the patient may vomit without 
nausea, almost without effort, so that the vomiting is rather an eruc- 
tation ; it often occurs without pain or without reference to the fulness 
or emptiness of the stomach; even though it is frequent, the nutrition 
may be remarkably good, the tongue clean, and the appetite good. 
Periodical or cyclical vomiting, described by Leyden, has some resem- 
blance to tabetic crises; Edsall considers it an acidosis, for which 
5ss to ij of sodium bicarbonate is indicated. Robert's conclusions 
are as follows: 

1. Vomiting of a chronic type, following a gradually developed 
epigastralgia, from one-half to three hours after the ingestion of food, 
is attributable to peptic ulcer, gastric or duodenal. 

2. Chronic vomiting that occurs from ten to fifteen minutes after 
food ingestion is attributable to stenosis of the cardia, nervous abnor- 
mality, cerebral lesion (occasional rather than chronic), or to protracted 
acute gastritis. 

3. Copious vomiting ten or more hours after food ingestion indi- 
cates a muscular insufficiency; frequent repetition indicates a per- 
manent lesion in the nature of a mechanical interference with the 
exit of food. 

4. Vomiting in the night is particularly liable to occur in chole- 
lithiasis, periodic hypersecretion, muscular insufficiency, and nervous 
abnormality. 

5. Vomiting attempts when the stomach is empty indicate a cause 
other than a gastric lesion, either a reflex cause, a toxaemia, a cerebral 
lesion, or a nervous abnormality. 



646 DISEASES OF THE DIGESTIVE TRACT 

6. Morning nausea and retching indicate either a beginning of preg- 
nancy, alcoholism, pharyngitis, nephritis, or a nervous abnormality. 

7. Periodic vomiting of clear gastric juice of normal or supernormal 
acidity in any considerable amounts indicates a secretory neurosis or 
an ulcerative lesion. 

8. Vomiting as a sequel of headache, accompanied by severe nausea, 
but no gastric or abdominal symptoms, characterizes attacks of mi- 
graine; in a majority of cases eyestrain is the underlying cause. 

9. Attacks of vomiting of sudden onset, with tinnitus, deafness, and 
vertigo, are attributable to disturbances of pressure in the internal or 
middle ear. 

10. Periodic attacks of vomiting of sudden onset, associated with 
more or less severe gastric pain and nausea, retraction of the abdomen, 
obstinate constipation during but not preceding the attack, and free- 
dom from abdominal tenderness, are suggestive of the spinal crises, 
idiopathic nervous vomiting, and lead-poisoning. 

11. Periodic attacks of vomiting after abdominal colic and consti- 
pation, with localized or general tympany, are suggestive of chronic 
intestinal stenosis. 

2. Depressive Motor Neuroses (from Lessened Motility). — There 
are three types: (a) Atony, which has been considered under dilata- 
tion; (b) pyloric insufficiency (Sere and Ebstein), which is seldom 
a neurotic condition, as compared with its frequency in cancer, ulcer, 
and dilatation of the pylorus from duodenal obstruction. Its presence 
is determined by inflating the stomach with carbon dioxide, which 
rapidly passes into the intestine with a gurgling gush, (c) The third 
type, insufficiency of the cardia, causes regurgitation of food and fluid 
and rumination (merycismus) , which is a regurgitation in which the 
food is again chewed and reswallowed. These are generally involun- 
tary processes, but some subjects can regurgitate at will. The patients 
are nearly always neurotic males, psychopaths, or idiots. The affection 
is either hereditary or (which is more likely) imitative when it occurs in 
several members of a family. Its mechanism is a matter of theory; 
congenital weakness of the cardia, stimulation of the vagus, and 
aspiration into the oesophagus by the inspiratory act, are considered 
causal. It should be treated by giving small meals at frequent intervals ; 
these should be well masticated; intragastric electrical applications 
and suggestive measures are indicated. 

III. Sensory Neuroses of the Stomach. 

1. Hyperesthesia may give the sensation of burning in the stomach, 
or a sense of weight; this usually occurs when the organ is full, but 
at times also when it is empty. Certain kinds of food, as carbohydrates, 
fats or spices may induce the condition. Silver nitrate, gr. -J- to J> ac. 
carbolicum gr. J to j, or extr. gelsemii fl. Ttjuj, given on the empty stom- 
ach, often afford relief, besides which the basic neurasthenia should 
receive treatment, and perhaps also the anaemia or constipation. 



SENSORY NEUROSES OF THE STOMACH 647 

2. Gastralgia (gastrodynia or cardialgia, which is a poorly selected 
but widely used term) does not strictly include the gastric pain due to 
ulcer, hyperacidity, or hypersecretion. Rosenthal's etiological classi- 
fication is as follows: (i) Cerebrospinal causes, including various brain, 
cord (tabes), peripheral, and functional nervous affections, (ii) Con- 
stitutional causes, including chlorosis and debility, (hi) Toxic causes, 
resulting from gout, rheumatism, malaria, and from nicotine and con- 
stipation, (iv) Reflex causes, from the genito-urinary and alimentary 
tracts; for example, from floating kidney, intermittent hydronephrosis, 
splanchnoptosis, uterine or ovarian disease, or masturbation. Fliess 
holds that many cases of both dysmenorrhea and gastralgia arise 
from disease of the lower nasal turbinates. Most cases occur in women 
between fifteen and forty-five years of age. 

Symptoms. — As the term implies, the affection occurs with severe 
gastric pain which begins suddenly, often at night, lasts for a few 
minutes to an hour or so, and subsides usually to recur after a variable 
interval. The pain is epigastric and may radiate widely. It bears no 
relation to eating, though food sometimes relieves it. Diffuse super- 
ficial tenderness or hyperesthesia over the stomach is not infrequent, 
but deeper pressure usually affords some relief. Vomiting is rather 
uncommon. Hiccough, hunger, headache, depression, polyuria, clammy 
sweats, small rapid pulse, or even collapse, may attend the seizure. 

Diagnosis. — A diagnosis is made only by exclusion and usually after 
the seizure is over. Rheumatic myalgia is more constant. A tabetic 
crisis is at once recognized by the Argyll-Robertson pupil, and the 
absent knee-jerks. Intercostal neuralgia gives Valleix's three tender 
points, which, however, are quite frequent in neurotic subjects. In 
ulcer (q. v.) or circumscribed peritonitis, the pain is associated with 
localized tenderness. Hyperacidity and hypersecretion should be 
excluded. Biliary colic {q.v.) is more difficult to differentiate, and it 
is well to remember that icterus is absent in the majority of cases of 
gall-stones, but a sharp thrust over the gall-bladder during deep inspir- 
ation nearly always elicits well-localized tenderness. 

Treatment. — Treatment is that of (a) the etiology, especially the 
neurasthenic condition, ansemia, and constipation. Fowler's solution 
w$i] before meals is excellent, (b) The attack must be treated. Mor- 
phine hypodermatically affords the only certain immediate relief, but 
in these very cases may establish the habit. If given at all, it should 
be given by mouth without the patient's knowledge. Heat and sinap- 
isms may relieve or aggravate the attack. Silver, carbolic acid, or 
gelsemium employed in hyperesthesia often give relief, as may extract 
of belladonna \ grain, cocain \ grain, charged waters, chloroform and 
Hoffmann's anodyne aa tt#xx to xxx, and galvanization with the anode 
to the epigastrium and cathode to the spine, though the attack is often 
over before application is possible. 

3. Disturbances may occur in the sense of hunger and appetite. 
Loss of appetite {anorexia) may be purely nervous, though it is more 
commonly due to gastric affections, fevers, tuberculosis, or toxins. As 



648 DISEASES OF THE DIGESTIVE TRACT 

described under Hysteria, anorexia nervosa may be absolute and cause 
profound emaciation, as described in the extreme cases of Lasegue, 
Wallet, and Brissaud. Parorexia is perversion of the appetite, in 
which the patient craves for unusual kinds of food. In polyphagia 
the appetite is enormous, but is capable of satiation; in boulimia 
(hyperorexia) the intense craving for large quantities of food comes 
on paroxysmally, sometimes with vertigo, palpitation, and other neu- 
rotic manifestations; polyphagia and boulimia are most frequent in 
hyperchlorhydria, hypersecretion, and hypermotility, but also occur in 
diabetes, focal brain disease or tumors, intestinal parasites, or from 
certain drugs as quinine, orexin, or even opium. Acoria is loss of the 
sense of satiation. These anomalies are central and probably result 
from organic or functional changes in the bulbar hunger centre. The 
treatment of the neurotic forms is that of the causal neurasthenia or 
hysteria. 

IV. Mixed Neuroses of the Stomach. 

Mixed neuroses, dyspepsia nervosa (Leube), neurasthenia gastrica 
(Ewald), or pseudodyspepsia, is marked by no stereotyped symptoms. 
It may occur alone as a species of local neurosis; it is sometimes reflex 
from other organs, but is much oftener a part of the neurasthenic 
symptom-complex. Leube's original contention that digestion itself 
is normal must be modified, as the hydrochloric acid may be increased, 
normal, or decreased. In many cases and perhaps in the majority the 
gastric functions are nearly or quite normal. Two main groups of 
symptoms prevail; (a) the centric, neurasthenic, or hysteric apathy, 
irritability, and vertigo; (6) the gastric eructations, variations in appe- 
tite, oppression, and diffuse tenderness, which are probably also centric 
(cerebral) in origin. The symptoms vary greatly in degree, often 
change their form with considerable rapidity, and the general nutrition 
is generally good. Organic disease must be carefully excluded by 
repeated examinations of the secretions and motility of the stomach, 
for nervous dyspepsia is too often "a collective term to cover incorrect 
diagnoses." The treatment is that of the neurotic basis; rest, regula- 
tion of worry and strain, self-control, and suggestion, are important. 



DISEASES OF THE INTESTINES. 

(A). ACUTE ENTERITIS; 

It is difficult to draw a close distinction between acute catarrhal 
enteritis, intestinal dyspepsia, and simple diarrhoea. Catarrhal enteritis 
is the most common intestinal disease. 



ACUTE ENTERITIS 649 

Etiology. — 1. Primary Forms. — (a) Errors in diet, and the inges- 
tion of spoiled food containing ptomaines, unripe fruit, and impure 
water, are common causes, (b) Disturbance in intestinal secretion 
may possibly occasion acute enteritis, though little is known of the 
succus entericus. (c) Cold, trauma, foreign bodies, particularly faecal 
retention, and toxins eliminated from the blood, may initiate inflam- 
mation, (d) Some cases are infectious, though our knowledge of them 
is still imperfect. Bacteria are undoubtedly an important factor; it is 
stated that one-third of the weight of the normal stool is caused by 
bacteria, of which 48 species are normally present ; acute inflammation 
may arise from pathogenic organisms or from virulence attained by 
some inhabitant of the intestine; the Bacterium coli is the most impor- 
tant, and Gaertner's Bacillus enteridis is probably one of its manifold 
forms. In a milk diet the Bacterium lactis aerogenes, and in a meat diet 
the Proteus vulgaris, may be possible factors. 

2. Symptomatic Forms. — (a) Enteritis is constant in some in- 
fections, from the action of microorganisms or their toxins, as in 
typhoid; it is frequent in others, as in sepsis, or influenza; and rare in 
others, as in measles, scarlatina, rheumatism, or malaria, (h) General 
diseases, as nephritis; (c) burns; (d) local intestinal diseases, as 
intestinal parasites, ulcers, or tumors; and (e) metallic or other poisons 
are etiological factors; (/) stasis is usually listed as a factor, but is 
rarely by itself a potent cause. 

Pathology. — The pathology is that of other inflammations of the 
mucous membranes; viz., redness, swelling, increased mucus secretion, 
parenchymatous degeneration, and some interstitial infiltration with 
leukocytes. In the few cases coming to autopsy these changes may not 
be at all conspicuous, as they regress soon after death. In some cases 
follicular swelling or even ulceration may be observed as well as 
punctate ecchymoses, catarrhal erosions, or slight swelling of the 
mesenteric glands. 

Symptoms. — The chief symptom is diarrhoea, due to increased 
peristalsis, increased secretion, or actual inflammatory exudation. 
The stools number two to fifteen daily, contain more or less mucus, and 
are variously colored; they may be brown-yellow with moderately 
frequent, or colorless and odorless with very frequent evacuations; 
their reaction is commonly alkaline or neutral; they contain triple 
phosphates, calcium phosphate, and oxalate crystals, sometimes 
cholestearin and Charcot-Leyden's crystals, but rarely leukocytes in 
any considerable number. There may be concomitant acute gastritis. 
Thirst, dryness of the mouth, colic pains, borborygmus, visible peris- 
taltic movements, tympany, and slopping or gurgling in the intestine, 
are frequent. Fever is unusual, though febrile forms with acute splenic 
tumor are recorded, which may at first resemble typhoid. Albumin- 
uria, cylindruria, or even acute nephritis, may develop in exceptional 
cases; the urine is scanty in proportion to the amount of fluid lost by 
the bowel; indican, etherial sulphates, and acetone, may be present. 
In some few cases herpes or muscle and joint pains occur. Collapse 



650 DISEASES OF THE DIGESTIVE TRACT 

is rare in adults, though cases occur which bear a close resemblance to 
cholera. In the vast majority of cases convalescence is established in a 
few days. 

Diagnosis. — (a) Duodenitis can seldom be diagnosticated; pain and 
tenderness over the duodenum are of most uncertain, and catarrhal 
icterus is of somewhat presumptive value in diagnosis, (b) Jejuno- 
ileitis seldom exists alone; diarrhoea is absent if the colon is not 
affected; the stools contain intimately mixed mucus, which often appears 
as small hyaline globules under the microscope (Nothnagel). (c) In 
enterocolitis, the bile is decomposed below the small intestine; when it 
is present in the stools it signifies increased peristalsis which moves the 
bile along before it can be disintegrated, and indicates acute entero- 
colitis ; bile may be found only in the small globules of mucus and not 
in the fluid evacuation. Many undigested food particles (lientery) are 
found, and this is rather significant if fever, biliary or pancreatic ob- 
struction, and gastric atrophy, are excluded; they consist of undigested 
meat, starch granules (which are more significant than muscle fibers), 
and fat particles, (d) Colitis is characterized by the absence of bile and 
lientery, by thin stools, and by more or less mucus, which is obtained 
especially on washing out the bowel immediately after a movement 
(Boas), (e) Proctitis is marked by much tenesmus, dysuria, evacu- 
ation of mucus alone, and the passage of bloody mucus covering but not 
mixed with the solid stools ; it is also diagnosticated by the local exami- 
nation with the finger or speculum. 

Treatment. — (a) In the early stage, evacuation of the causal irritant 
is indicated, to which end fractional doses of calomel should be given, 
followed by castor oil; the stronger evacuants, which may of themselves 
irritate or inflame the intestine, should be avoided. Colonic flushings 
with pure water, or injections of olive oil, may be added, (b) Absolute 
rest in bed is always indicated, (c) The diet should be restricted to 
barley water, or no food should be given for a day or two. (d) Heat 
should be applied to the abdomen, (e) A dram each of paregoric 
and bismuth should be given after each bowel movement until their 
number is controlled. A quarter of a grain of extract of belladonna 
relieves colic. The following preparation is excellent; the amount for 
a child being given in the first and the amount for an adult in the secord 
column : 

R 

Phenylis salicylate (salol) gr. xx. 3 j • 

Sodii bicarbonatis 5ss. 3j. 

Cretan preparatae 3ss. 5iss. 

Bismuthi subrritratis 5j- §J. 

M. et divide in pulveres X. 
S. — One powder in milk or thin arrowroot solution every three hours. 

Lack of tone is relieved by gambir (catechu), colic by belladonna 
and flatulency by ammonia and ginger: 



CHRONIC ENTERITIS 651 

Tincturse gambir compositse §j. 

Fluidextracti belladonnse gtt. xij. 

Spiritus ammonise aromatici 3ij. 

Tincturse kino 5j- 

Syrupi zingiberis §ss. 

Misturae cretae q.s. ad giv. 

M. et S. — A tablespoonful every two or three hours. 

Other astringents and intestinal antiseptics, as beta-naphthol gr. x p. 
c. in capsules, or 10 to 15 grains of tannigen (a compound of acetic acid 
and tannin), every two or three hours, are seldom indicated. (/) No 
laxatives should be given for the constipation resulting from this treat- 
ment, (g) Opium suppositories (see Dysentery) relieve tenesmus, 
(h) The diet may be increased in a few days to bouillon with raw egg, 
hashed beef or chicken, toast, zwieback, roast beef, and milk with equal 
parts of carbonated water; fruits and vegetables even when cooked 
should be given still later, and only with extreme caution, because 
recurrence readily predisposes to chronic enteritis. ({) Cramps, 
collapse, and other choleraic symptoms, are treated as in cholera (q.v.). 



(B). CHRONIC ENTERITIS. 

Etiology and Pathology. —The etiology is essentially that of acute 
enteritis, from repeated attacks of which, or of "acute indigestion," 
the chronic type may develop. 

Chronic enteritis always suggests a causative chronic gastritis, though 
both affections may result from a common cause, particularly over- 
eating and drinking. Chronic enteritis may follow chronic gastritis, 
achylia gastrica, and other gastric conditions ; or intestinal catarrh may 
cause anorexia, eructations, abdominal distention, and kindred 
symptoms. Hyperchlorhydria may disturb the intestines by the escape 
into them of more acid than they can neutralize; on the other hand 
hypo- or achlorhydria readily initiates bowel trouble because hydro- 
chloric acid bears an important relation to the intestinal and pancrea- 
tic secretions. 

The pylorus remains closed until the food in the stomach is ready for 
the intestinal juices and then it relaxes; the hydrochloric acid, reaching 
the duodenum, provokes a flow of bile (which arrests the action of the 
pepsin), and the acid also provokes the pancreatic secretion (which 
neutralizes the hydrochloric acid) by acting upon the duodenal mucosa, 
which gives off a substance known as "secretin," into the blood; 
secretin acting upon the pancreas causes it to secrete (Bayliss and 
Starling). When these ends are accomplished, the pylorus again re- 
laxes. When the pancreatic juice is poured out, it contains no active 
proteolytic ferment, but in the succus entericus there is an "activating" 
ferment (enterokinase) which converts trypsinogen into trypsin ; /. c. , the 
intestinal juice "activates" the trypsinogen (Pawlow). 



652 DISEASES OF THE DIGESTIVE TRACT 

The bile doubtless also increases the activity of the pancreatic 
enzymes or ferments; the action of the fat-splitting pancreatic ferment 
is enlivened threefold. 

The pathology of chronic enteritis is also similar to that of the acute 
type. In color the mucous membranes is brownish-red or slaty-gray. 
The mucosa and submucosa are often thickened, and the muscularis is 
sometimes hypertrophied. Polypoid hyperplasia and cystic degeneration 
of the intestinal glands as well as atrophic changes may result. Catarrhal 
erosions and follicular ulcers may occur as described under the last 
type of dysentery (q.v.). 

Symptoms. — Generally speaking, constipation is more frequent than 
diarrhoea; in comparatively few cases, a single soft morning evacua- 
tion is noted, or perhaps several; in others constipation is observed 
most of the time, broken occasionally by short attacks of colic and 
diarrhoea; continuous diarrhoea indicates inflammation of both the 
large and small gut. Constipation is due to alteration of the nervous 
fibers in the gut or to inflammation in the muscular coat. A sense of 
abdominal tension or colic may be present and is distinguished from 
gastric discomfort and pyloric spasm in that it occurs independently 
of ingestion of food. Diarrhoea results from decomposition and faecal 
irritation. There may be pain, flatulency, borborygmus, or occasion- 
ally tenderness over the bowels, which may occur together or at inter- 
vals; but the sole diagnostic criterion is the presence of mucus in the 
passages; an intimate mixture with the stool indicates inflammation 
in the small gut; a mere coating of the passages with mucus indicates 
colitis, and evacuations of mucopus alone, proctitis. Mucus may be 
seen as small sago-like globules, which are often vegetable matter. 
These globules when bile-stained indicate inflammation of the small 
gut, as do shreds of bile-stained mucus. Small homogeneous denucle- 
ated epithelial cells may be found in the mucus adhering to scybala. 
Pus cells are rare except in proctitis. The presence of mucus is always 
indicative of enteritis and never occurs from ulceration or carcinoma 
alone (a slight coating of mucus over hard faeces is not significant). 
Blood always indicates a complication, such as piles, ulceration, or 
cancer. The stools may contain much undigested meat, starch, or fat. 

Schmidt and Strasburger have proposed the functional examination 
of the faeces ; while their method does not give us as exact information 
as does the examination of the stomach, valuable facts may be deter- 
mined. Schmidt's test diet includes 1,500 c.c. (3 pints) of milk, 100 gm. 
(3 ounces) of zwieback or toast, two eggs, 50 gm. (1.6 ounces) of 
butter, 125 gm. (one quarter pound) of rare tender steak, 190 gm. (6 
ounces) of boiled potatoes, 60 gm. (2 ounces) of oat-meal, and 20 gm. 
(two-thirds of an ounce) of sugar; this total is variously distributed 
among the three meals. With the first meal a capsule of five grains of 
charcoal or carmine is given, and the first examination is not made until 
the stools become colored black or red. In this way (i) the "period of 
passage" is established, the normal time being ten to twenty hours. 
(ii) Mucus is detected, microscopically, by mixing a piece of faeces as 



CHRONIC ENTERITIS 653 

large as a walnut with a small amount of water; it appears as trans- 
lucent, sago-like, and often bile-stained flakes, which must not be 
confused with starch particles. (Hi) Much connective tissue, recog- 
nized by its yellow-white color and its toughness, indicates reduction of 
the hydrochloric acid, (iv) Muscle fibers, appearing as reddish 
threads or lumps, may indicate achylia gastrica, lack of trypsin, lack 
of the activating enterokinase, or very active peristalsis, (v) Free 
starch granules always indicate intestinal catarrh; normally only 
starch enveloped in cellulose is present, (vi) The normal stool shows 
hydrobilirubin, detected by mixing a small amount of the fluid faeces 
with an equal amount of a 5 per cent, solution of bichloride of mercury, 
which mixture turns yellow-red after twenty-four hours; bilirubin, 
recognized by a green color in the above test, always indicates catarrh 
of the small bowel (except in young children), (vii) The fermentation 
test is made by mixing a dram of the faeces with sterile water in a 
bottle which is connected above with a tube containing water; almost 
no gas results in normal cases; if the reaction becomes acid with a 
pathological fermentation, it is due to carbohydrate fermentation; if 
it becomes alkaline and foul in odor, it is due to proteid fermentation. 
(viii) With a little experience with the amount of fat normally found 
it can be readily determined whether the fat is pathologically increased. 

The appetite is usually good. The general nutrition is good in some 
cases, though in others, pallor, emaciation, slow pulse, and cold extrem- 
ities, may be noted. Attacks of diarrhoea, together with undigested 
food in the stools, should lead the physician to look for achylia gastrica 
(Einhorn, Oppler). 

Prognosis. — The prognosis, save in either extreme of age, is good as 
to life itself, but is always doubtful at any age as to complete recovery. 
Improvement is at the best tardy and too often transient. Intestinal 
atrophy may develop, though this is less frequent than in puerile forms. 

Treatment. — (a) Moderate exercise and an hygienic conduct of life 
are most essential. A flannel band should be worn over the abdo- 
men, (b) The diet must be carefully supervised. Though it is im- 
possible to give here a complete dietary, salads, beer, wine, fruits and 
vegetables of nearly every description, either raw or cooked, sweets, 
pickles, and acids, are among the forbidden foods, and the articles 
which may be given include eggs, fresh butter, lean meats, stale bread, 
rusks, thoroughly cooked rice or sago, and potato purde; i. e., simple 
foods, in small amounts and at frequent intervals, controlled by frequent 
examination of the faeces, (c) Regulation of the bowels is necessary. For 
constipation, purgatives should be avoided and the bowels moved by 
enemata of olive oil. Constipation is often due to the careful diet, which 
does not provoke peristalsis. For diarrhoea, bismuth in dram doses 
and tannigen or tannalbin (5 to 15 grains) are most efficacious (see 
Acute Enteritis). Calcium carbonate and salicylate are recom- 
mended by Boas and Javorski (aa 5ss to a quart of charged water; one- 
half glass q.i. d.). id) Flatulency — Some flatus is not pathological. 
As it results not from faecal stagnation alone, but from stagnation plus 



654 DISEASES OF THE DIGESTIVE TRACT 

catarrh (chiefly in the ileum, csecum, and ascending colon), the first 
indication is that of the catarrhal enteritis; the second is the restriction 
of foods which ferment (v. s.); and the third is the administration of 
aromatic remedies (see Therapy of Acute Enteritis). 

Menthol 3ss. 

Phenylis salicylates 5iij. 

Extracti belladonnse gr. iv. 

M. et ft. capsulse XX. 
S. — One after meals. 

(e) Colitis may be treated by medicated rectal flushings, 1 to 1,000 or 
2,000 silver nitrate, borax, salicylic acid, or ichthyol. (See Treatment 
of Dysentery.) 



(C). ENTERITIS (COLITIS) MUCOSA OR MEMBRANACEA. 

This disease was first described by Mason Good (1825), though the 
first classical description was Da Costa's in 1871. The name implies 
that the malady is an inflammation, but in reality most cases are neither 
enteritis nor colitis. Nothnagel proposed the name colica mucosa for 
the non-inflammatory variety, which is a secretory neurosis. 

Etiology. — (a) Eighty to 90 per cent, occurs in nervous or hysterical 
women between twenty and forty years old, 40 per cent, of whom have 
uterine troubles; males who are affected are usually nervous or hypo- 
chondriacal; a few cases have been seen in nervous children. (6) 
Nearly all cases suffer from years of previous constipation. Its pathol- 
ogy is unknown ; in some autopsies no anatomical alteration is noted, 
in others that of enteritis. 

Symptoms. — (a) Mucus casts of the bowels, shreds or lumps, are 
voided periodically; the mucus may resemble a huge diphtheritic cast, 
is usually evacuated in large amounts, which often constitutes the 
entire bowel movement, and contains very few leukocytes or other 
signs of inflammation; it is rarely simulated by curds of milk, (b) 
There is usually, but not always, colic or pain and tenderness with the 
attack, which frequently occurs over the splenic flexure of the colon, is 
sometimes diffuse, and occasionally radiates, as into the leg. If the 
mucus is firmly adherent to the bowel wall the pain is particularly 
severe, and obstruction of the bowels may be simulated very closely. 
Tenesmus in voiding the mucus is usual, as are formation of gas, and 
increase of the original nervous symptoms, as palpitation, tremor, or 
vertigo. There may also be coincident diarrhoea, achylia gastrica, and 
a periodic sand formation (Dieulafoy). (c) Constipation, abdominal 
distention or pressure and anorexia exist between the paroxysms, 
which last a day or even a week, and are separated by intervals of weeks 
or months. It is said that death may occur during an attack. 

Treatment. — Treatment concerns (a) the fundamental neurosis. 
As a rule, the less the neurotic symptoms are in evidence, the better 



DUODENAL PEPTIC ULCER 655 

are the results of therapy;, education, the rest cure, and other measures 
outlined in the treatment of hysteria and neurasthenia (q.v.), are in- 
dicated, (b) Constipation (v. i.) is treated in the usual way, and an 
appropriate diet is essential. It has been maintained by von Noorden 
that the diet usually given in spastic constipation is not appropriate; 
he advises the use of graham bread, leguminous vegetables, including 
the husks, vegetables with much cellulose — which seems to be the 
most important element — fruits with small seeds and thick skins, as 
gooseberries, currants, or grapes, large amounts of cream, butter and 
bacon, and olive oil. Von Noorden's results with this diet are: 79 per 
cent, cured (15.8 per cent, partially cured, 50 per cent, permanently 
cured, 13 per cent, relapsed), 15.8 per cent, unknown result, and 5.2 
per cent, failure. In White's series 50 per cent, recovered, 13 per cent, 
improved, and 37 per cent, were not improved, (c) Local measures 
include colonic flushings with normal salt solution, or half a pint of 
olive oil left in the rectum over night (Kussmaul) . (d) Narcotics, pur- 
gatives, irrigation with alum, tannin, and silver solutions, and operations 
are distinctly contra-indicated. The morphine habit may be readily 
contracted; if given at all, morphine is exhibited with belladonna as a 
suppository. The patient in an attack is kept in bed and heat is applied 
to the abdomen. 



(D). DIPHTHERITIC, CROUPOUS, AND PHLEGMONOUS 
ENTERITIS. 

True diphtheria, due to the Klebs-Loeffler bacillus, is very rarely 
encountered, and practically all membranous enteritis is diphtheroid; 
it develops in various acute infections, in uraemia, and in metallic 
poisoning, and has been described under the third form of dysentery. 

Phlegmonous or purulent enteritis is likewise extremely rare and 
chiefly of anatomical interest. Most cases develop in the duodenum. 
The affection may be primary, but more often is secondary to intestinal 
ulceration, carcinoma, or intussusception. Maragliano described a 
form probably due to the colon bacillus, in which multiple purulent 
foci are found in the intestinal wall, which frequently cause perforation. 

(E). INTESTINAL ULCERATION. 
I. Duodenal Peptic Ulcer. 

This is almost identical in etiology, pathology, and treatment, with 
the peptic gastric ulcer. 

Etiology. — (a) Gastric ulcer is 10 to 40 times as frequent as duodenal 
ulcer, whose frequency Kinnicutt estimates at & per cent, in 30,000 
autopsies. In 121 duodenal ulcers collected by Oppenheimer, gastric 
ulcer was present in about 6 per cent., and in Lebert's series of 237 



656 DISEASES OF THE DIGESTIVE TRACT 

stomach ulcers, duodenal ulcer was present in about 10 per cent. 
Moynihan found gastric ulcer in about 50 per cent, and Mayo in 22 
per cent. Thirty-one cases of intestinal ulcer are reported after gastro- 
enterostomy for round ulcer of the stomach (q. v.); ulceration may be 
obviated by alkalies after operation, (b) Seventy-nine percent, occurs 
in males as a result of alcohol and tobacco, (c) In Collin's series of 
279 cases, two-thirds occurred between twenty and sixty years of age, 
being about equally frequent in each decade, (d) Other etiological 
factors are: (i) in extensive burns (Curling, 1842) acute ulcers develop 
in one to two weeks, rarely earlier or later; Holmes found them in 
13 per cent, of 125 fatal burns; their cause is probably vascular ob- 
struction, though the precise factors are not yet established (fibrin- 
ferment, toxins absorbed from the skin, aggregation of blood plaques), 
(ii) Nephritis, which occurs in 17 per cent, of the cases, is suggested 
as a cause by Perry and Shaw, (iii) It may result from embolism 
and thrombosis. Endocarditis and sepsis occasionally cause duodenal 
ulcer. Thrombosis of the umbilical and other veins produces the cases 
seen in the new-born (Landau). It has also followed trauma, multiple 
neuritis, periarteritis nodosa, and foreign bodies such as gall-stones. 
Pathologically the resemblance to gastric ulcer is marked in all details. 
It is single in 84 per cent., is located in the upper horizontal part in 
87 per cent, of cases, and is almost always above the papilla. 

Symptoms. — Symptoms are absent in 30 to 60 per cent., at least 
until hemorrhage or perforation occurs. This clinical latency is ex- 
plained by absence of gastric hyperacidity, motor insufficiency, and 
peritonitis, (a) It is generally stated that gastric symptoms are absent 
in the great majority of cases. C. Graham, in an analysis of 46 cases 
operated by Mayo, found stomach symptoms, especially vomiting and 
gas formation, in about 70 per cent. The appetite is usually good. 
It is usually stated that the hydrochloric acid is not increased ; Graham 
found superacidity in about half the cases. It must be remembered 
that associated gastric ulcer is quite frequent. The writer's views 
regarding the value of hyperacidity in gastric ulcer (q.v.) have been 
given. In one of his cases of gastric ulcer in which there was anacidity, 
Murphy found at operation a gastric ulcer and also a greatly dilated 
duodenum; in the jejunum there was marked stenosis due to a healed 
round ulcer, as shown by microscopic examination. This case is, as 
far as we know, quite unique; Tobiesen reports a jejunal ulcer follow- 
ing burns. (b) Pain often occurs three to six hours after eating, and is 
located over the duodenum, and is sometimes accompanied by tender- 
ness. Both pain and tenderness may be peritonitic. (c) Hemorrhage 
from the bowels occurs in 33 per cent, of cases. Darras estimates it at 
75 per cent. The stools are usually tarry, but are sometimes bright 
red from copious bleeding. "Occult" hemorrhage (small or micro- 
scopic hemorrhage) is even more common, and is as important as in 
gastric ulcer or cancer. Intestinal hemorrhage is often fatal from 
erosion of the pancreatico- or gastro-duodenal arteries, less often of 
the aorta or cava. Hsematemesis is infrequent, though it has been said 



OTHER INTESTINAL ULCERS 657 

to occur in a quarter of the cases where there is intestinal hemorrhage ; 
hsematemesis usually indicates duodenal stenosis, in which the blood 
passes more readily upward than downward. Constipation is frequent. 

Complications and Issue. — (i) Spontaneous healing is infrequent, 
and the clinical course is often long (five to thirty years), (ii) Per- 
foration, total with peritonitis, or partial (chronic) with gall-bladder or 
pancreas symptoms, is very frequent (50 per cent., Perry and Shaw), 
and is even thought to be as high as 69 per cent, (iii) Gastric dilata- 
tion occurs in 7 per cent, and duodenal dilatation in nearly 2 per cent. ; 
both result from duodenal stenosis, (iv) Icterus occurs in less than 
3 per cent.; (v) duodenal cancer is an infrequent sequel. 

Diagnosis. — Leube holds that a certain differentiation from gastric 
ulcer is never possible, and one is impressed with the frequency of 
symptoms of gastric ulcer in many reported cases. Von Wyl holds 
that differentiation from gastric ulcer is possible in but 10 per cent, 
of cases. The other chief cause of error is disease of the gall-bladder. 
As Graham states, "There will always remain a certain proportion 
of cases that will mislead the careful physician. Those cases of gall- 
stones in which the stomach symptoms of gas, distress, sour belching 
and dilatation predominate, and pain is only of a dull character, will 
usually be diagnosticated as ulcer; but the duodenal case, of which 
the chief symptom is the sudden, sharp, intense pain of perforative 
peritonitis, and in which, with no obstruction or hyperacidity, the other 
stomach symptoms are in abeyance, will be diagnosticated cholelithi- 
asis. Both conditions are purely surgical, and the differentiation in 
many cases must be made on the operating table." Acute pancreatitis 
(q. v.), intestinal obstruction, and appendicitis, must be considered in 
the diagnosis. 

Treatment. — The treatment is that of peptic ulcer of the stomach 
(q. v.), including its surgical indications. The operative mortality 
ranges from 70 to 85 per cent. Moynihan in 52 operations (1905) 
obtained these results: in 7 perforations, 71 per cent, recovered; in 
22 chronic ulcers, 95.5 per cent, recovered; in 22 ulcers associated 
with gastric ulcer, 95.5 per cent, recovered. 



II. Other Intestinal Ulcers. 

Ulceration in acute infections, as typhoid, dysentery, anthrax, and 
diphtheria, has been described. In exceptional cases ulceration may 
occur in erysipelas, variola, and sepsis. Chronic infections may cause 
ulcers, as syphilitic, tuberculous, and actinomycotic lesions; these are 
considered under general infections. Very rare cases of ulceration 
have been observed from favus and mucor corymbifer. Inflammatory 
ulcers, as the catarrhal and follicular, usually occur in the colon; they 
may be simple or (so-called) dysenteric (q.v.) and may develop from 
the epithelial layer; they are seen in enteritis, infantile diarrhoeas, 
and fevers. Stercoral (decubital) ulcers develop from the pressure of 

42 



658 DISEASES OF THE DIGESTIVE TRACT 

retained hard faeces or foreign bodies, and occur in the dilated pouches 
of the colon or above an intestinal stenosis. Constitutional affections 
are occasionally causes, as leukaemia, scurvy, gout, and amyloidosis. 
Toxic ulcers may develop in uraemia (q.v.), and in mercurial and 
arsenical poisoning. 

Symptoms. — The symptoms are rarely distinctive without suggestive 
etiological factors; most ulcerations occur without symptoms or with 
ambiguous symptoms, (a) Diarrhoea is frequent, particularly in ulcer- 
ation of the large gut; it is often absent with lesions in the small gut 
or in the upper colon. Diarrhoea results from decreased absorption 
and from increased peristalsis, due to exposure of the intestinal nerves. 
(b) Blood in the stools is mixed with them in lesions of the small gut, 
sometimes covers them in lesions of the large gut, and is voided inde- 
pendently of the faeces in rectal lesions. It is more often dark and 
tarry, especially in tuberculosis, than bright, except in low-situated 
lesions and in some profuse typhoid, dysenteric, or duodenal hemor- 
rhages. It is not common in nontoxic enteritis. Blood is common in 
other diseases than ulceration, as in cancer, piles, stasis, and blood 
diseases, (c) Pus is seen more frequently in colonic than in ileac 
ulceration; it is common in cancer, proctitis, and croupous enteritis. 
Pure pus in considerable amounts is rather indicative of rupture of 
extra-intestinal pockets into the intestine, as appendicitic and sal- 
pingitic abscesses, (d) The presence of mucus has no special signifi- 
cance, as it indicates enteritis only, which of course may complicate 
ulceration, (e) Shreds of tissue are very rare, save in dysentery. (/) 
Local symptoms are likewise ambiguous, as tenderness, pain, and tym- 
panites, (g) General symptoms depend on the basic disease; fever is 
most frequent in cancerous, dysenteric, or tuberculous ulcer, (h) 
Rupture causes peritonitic adhesions, diffuse peritonitis, retroperito- 
neal cellulitis, or subphrenic pneumopyothorax. 

Treatment. — Treatment is that of enteritis or colitis. Of chronic 
ulcerative colitis Mehrkorn has published 38 cases in which colostomy 
resulted favorably. 



(F). INTESTINAL DISORDERS IN INFANTS. 

Etiology. — Classification of the etiological factors is extremely diffi- 
cult because of the numerous species of bacteria in the intestine and 
the impossibility of drawing any absolute line between chemical and 
bacterial factors and between functional and organic changes. Most 
cases occur in children between six and eighteen months old, in 
the summer months, July especially, and in the poorer classes. It 
occurs largely in infants who are not fed at the breast, and for two 
main reasons; (a) cow's milk is prone to disturb digestion (see 
Treatment), and (6) there is a greater chance for bacterial infection. 
Bacteria operate in several ways. Vaughan and Fluegge have demon- 
strated that toxins may form in milk. This factor is especially potent 



INTESTINAL DISORDERS IN INFANTS 6 > ) 

when milk is long in transit, particularly in hot weather. Bacteria 
may cause inflammation of the intestines; the Bacterium lactis aerogenes 
causes inflammation in the small and the Bacterium coli in the large 
intestine; the proteus, pyocyaneus, pyogenic cocci, and, since 1897, 
Shiga's Bacillus dysenterise, are also factors, but their relative import- 
ance is not yet clearly defined. Escherich, Booker, and Favel describe 
a streptococcus enteritis, which, however, can hardly be considered as 
a distinct type; Baginsky considers the saprophytes of the intestine 
and of cow's milk causative, and Czerny holds that toxins may develop 
in the liver. The distinction between intoxication and infection is 
maintained with difficulty; intoxication causes such symptoms as 
erythema, hemorrhagic diathesis, ansemia, nervous disturbances, and 
dyspnoea; and infection produces certain complications as lobular 
pneumonia, nephritis, encephalitis, phlegmon, arthritis, purulent 
pleurisy, and necroses in the liver. In some institutional epidemics, 
infection may be carried from one individual to another by faecal con- 
taminations. Insects may also convey infection. 

Symptoms. — (1) The symptoms of the acute dyspeptic or fermental 
form cannot be sharply distinguished from those of the other severer 
forms, though possibly caused by the same microorganisms. The 
pathological findings are often, as in adult forms, remarkably insignifi- 
cant. The temperature usually rises suddenly to 103 or 104 degrees, 
remains high for a few days, and falls rather suddenly. The tongue is 
dry, the face red, the pulse rapid, and the breathing sometimes dys- 
pnceic (Czerny). There is considerable restlessness — sometimes initial 
convulsions — anorexia, and vomiting. The stools in infants are nor- 
mally yellow from bilirubin, which is not decomposed, are thick, and 
slightly acid in reaction ; they become greenish from bacterial action or 
reduction of the bilirubin into biliverdin, react alkaline from albumin- 
ous decomposition or acid from acid fermentation, and become thin 
and offensive; the evacuations become frequent (6 to 10 daily). The 
microscopic findings are those of acute enteritis in adults, as mucus, 
leukocytes, triple phosphates in the alkaline stools, or cholestearin in 
the acid stools; blood in any quantity is uncommon. Involvement of 
the small intestine is attended by considerable formation of gas, some 
cramping, large movements, and slight tenderness and tenesmus. In 
severe cases the nervous symptoms may become conspicuous and con- 
siderable emaciation may result. Albuminuria occurs in about 20 per 
cent, and in many cases is attended by cylindruria. The author has 
seen two cases of extensive oedema follow dyspeptic diarrhoea without 
albumin or casts. Recovery is usual and prompt after thorough 
intestinal evacuation, though some few cases run a subacute or chronic 
course. 

2. Cholera infantum occurs in the severest cases and usually in 
children already suffering from some intestinal disorder. According 
to Holt, it constitutes but 2 to 3 per cent, of summer diarrhoeas. The 
bowel movements are copious, alkaline, and contain flocculi; though at 
first they contain food and are perhaps offensive, they become watery 



660 



DISEASES OF THE DIGESTIVE TRACT 



and odorless. Both the stools and the general clinical aspect resemble 
the picture of cholera Asiatica and cholera nostras (q.v.). Though 
there is fever, the extremities are algid and cyanotic, the pulse small, 
the heart tones weak, and all the symptoms of collapse are present; 
the eyes are sunken, and there is the pinched pallid fades cholerica, 
the thirst, and the incoercible vomiting. The skin is rigid, as though 
the fatty tissue had hardened (scleredema or sclerema adiposum), and 
nephritis is almost invariably present. These symptoms result not 
only from loss of great quantities of fluid by purging and vomiting, 
but also from intoxication which produces the convulsions, irregular 
and Cheyne-Stokes breathing, retraction of the neck, stupor, and other 
symptoms grouped by Marshall Hall under the term "hydren cephalic 
state," and explained by him as due to oedema of the brain (q. v.), 
though better explained by intoxication. Oestreich thinks that hypo- 
stasis, resulting from compression of the lungs by the tympany, causes 
more deaths than does the toxsemia. 

3. Acute enterocolitis (ileocolitis) may follow the dyspeptic form or 
the various specific infections in children, or may begin as an inde- 
pendent form. Pathologically it includes types which cannot be sepa- 
rated clinically, as (a) simple enterocolitis, (b) follicular ulceration, and 
(c) diphtheroid enteritis. The growing importance of Shiga's Bacillus 
dysenteric in infantile enterocolitis is established by the recent work 
in this country of Vedder, Duval, Flexner, Bassett, Knox, Park, Za- 
horsky, Dunham, Woll stein, and Rotch. In some epidemics the bacillus 
which is found produces acid in mannit media, which Shiga's bacillus 
does not produce. In Rotch's cases of infantile diarrhoea the Bacillus 
dysenterise was found in 16 per cent.; it was sometimes found in the 
dyspeptic or fermental type, but most often in the ileocolitic type 
(78 per cent.). In one collection of 412 cases Shiga's bacillus was 
found in 63 per cent. ; Geo. Weaver never found it, though the Flexner- 
Harris type occurred in 25 per cent. (v. Bacillary Dysentery). 

The symptoms rather closely resemble those of dysentery in the 
adult. The stools are small, yellow, green, or brown, are very frequent, 
are attended by tenesmus and void mucus, blood, pus, and sometimes 
shreds of tissue or membrane. Blood may be present from congestion 
or acute ulceration. Rotch tabulates the differential features as 
follows : 



Acute Fermental Diarrhoea. 


Acute Ileocolitis. 


(a) 


Small intestine, mostly. 


Large intestine, mostly. 


(6) 


10 to 12 discharges; often large. 


10, 15, to 50 discharges, usually small. 


(c) 


No or little blood. 


Blood and sometimes shreds of tissue or mem- 
brane. 


id) 


Mucus. 


Mucus. 


(e) 


No tenesmus. 


Tenesmus. 


(f) 


Not much, abdominal tenderness and pain. 


Abdominal tenderness and pain. 


(g) 


No or slight lesions. 


Lesions marked. 


(h) 


Temperature high — 104° F. for one or two 


Temperature may be high at first (103° F.^to 




days, and then falling sharply by crisis. 


104° F.) but usually soon moderates (99°|to 
101° F.) and falls gradually by lysis to normal 
after some weeks. 



INTESTINAL DISORDERS IN INFANTS 661 

The severity of the symptoms varies greatly; the catarrhal form 
may cause mild symptoms or result in death, with or without gastric 
symptoms. The ulcerative and diphtheroid types are less often at- 
tended by vomiting, but run a fatal course of days or weeks. 

4. Chronic dyspeptic disturbances often occur with gastric dilata- 
tion. The onset is gradual or it may directly follow the acute forms. 
The stools are green or gray, contain mucus, gas, and sometimes pus 
and tissue shreds. Food and fluid are not absorbed, or absorbed in 
part only; undigested food particles and fatty stools are observed; 
mucus is not common in marked cases of intestinal atrophy. Vomiting 
is rather frequent. There is usually but little general disturbance, no 
fever, and little or no colic. The scales show marked loss in weight 
and in some cases the emaciation may become extreme (panatrophy, 
athrepsia), the muscles becoming weak, the voice faint, the eyes luster- 
less, the face of the " Voltaire type," and the abdomen distended. 
Death results from marasmus or intercurrent infections. 

Preventive Treatment. — Children should if possible be taken to 
the country in the hot months. Excessive swaddling is to be avoided. 

Diet. — (a) Human milk is superior to all others, and if the mother 
cannot nurse her child, a wet-nurse should be procured if possible, as 
few cases of stomach and bowel disease occur in breast-fed infants. 
The wet-nurse must be carefully examined for syphilis and tubercu- 
losis. The milk from the breast should spurt freely in several streams. 
A weak child may become dyspeptic even at the breast, and a fraction 
of a grain of calomel and magnesium carbonate give the most rapid 
relief. Other children thrive, even when the stools are green, for which 
Heubner blames the digestion of the infant. Sometimes colic and 
dyspepsia in the child are due to menstruation, beginning of pregnancy, 
excitement, lack of exercise, or alcoholic indulgence in the nurse or 
mother. If a wet-nurse cannot be obtained, (b) cow's milk or some 
prepared food must be used, but most of the latter are objectionable 
because their carbohydrates are not dextrinized, as shown by the iodine 
test. Cow's milk differs from human milk in many details; its con- 
tamination is far more likely, whence the importance of pure milk and 
sterilized nipples and bottles. Human milk contains about 1 per cent, 
of proteids, 4 per cent, fats, and 7 per cent, of milk sugar, but in cow's 
milk the percentages are respectively, about 3.5, 3.5 and 5 per cent.; 
in cow's milk the casein constitutes 80 per cent, of the proteids, which 
are physically and chemically different in mother's milk; e.g., they 
contain more whey proteid and more of certain relatively uninvesti- 
gated substances, as nucleon. In cow's milk the ferments and fats 
are different and the mineral salts, especially phosphates, are increased 
which, as Blauberg has shown, increases the difficulty of digestion. 
The first objection is the high percentage of proteid (casein), which 
must be predigested, or otherwise the milk must be diluted. Simple 
dilution, however, necessitates giving too much water or reducing the 
fat and milk-sugar, fat being essential not only as a food but as an 
energizer, and milk-sugar being important because the Bacillus Iactis 



662 



DISEASES OF THE DIGESTIVE TRACT 



aerogenes, operating upon it, produces lactic acid, which is inimical 
to pathogenic bacteria in the bowel. In modification of milk or in 
substitute feeding, then, the proteid of cow's milk must be reduced, fat 
added in the form of cream, and milk-sugar added to attain the normal 
percentage. The milk may be diluted with thin oatmeal water, as a 
diastase ferment is present earlier and in larger amounts than pre- 
viously admitted, though nature doubtless has her designs in with- 
hblding carbohydrates from mother's milk. The fats of Holstein, 
Durham, Devon, and common breeds, can be better emulsified than 
those of Jerseys and Guernseys, which contain more volatile glycerides. 



Theoretical Basis 


for Feeding A Healthy Infant. 










(According 


to Rotch). 
















Proteids if 
split. 


Amount at 

each feeding, 

in — 


£ o 

^3 


a 


Age. 


Fat. 


Sugar. 


Pro- 

teids. 




m 


§5 a 5 


Whey 
pro- 


Case- 


Ounces. 


C. c. 


x ." o 

9 ^th 










teids. 


mogen. 








fc 


Premature 


1.00 
1.50 
2.00 
2.50 


4.00 
4.50 
5.00 
5.50 


0.25 
0.25 
0.50 
0.50 


0.25 
0.50 
0.50 
0.50 


0.25 
0.25 
0.25 
0.25 


i-f 

*-! 

l 
H 


4-25 
4-25 
30 

45 


2 
2 


24-18 


Premature 


24-18 


At term 


10 


End of second week . . . 


10 


End of third week 


3.00 


6.00 


0.75 


0.75 


0.25 


2 


60 


2 


9 


End of fourth week 


3.50 


6.50 


1.00 


0.75 


0.50 


2i 


75 


2 


8 


End of sixth week 


4.00 


7.00 


1.00 


0.90 


0.60 


3 


90 


2* 


8 


End of eighth week. . . . 


4.00 


7.00 


1.25 


0.90 


0.75 


3* 


105 


24 


7 


End of twelfth week. . . 


4.00 


7.00 


1.50 


0.90 


1.00 


4 


120 


24 


7 


End of four months . . . 


4.00 


7.00 


1.50 


0.75 


1.25 


H 


135 


24 


6 


End of five months. . . . 


4.00 


7.00 


1.75 






5J> 


165 


3 


6 


End of six months 


4.00 


7.00 


2.00 








6 


180 


3 


6 


End of eight months . . 


4.00 


7.00 


2.50 








7 


210 


3 


6 


End of nine months . . . 


4.00 


7.00 


3.00 








8 


240 


3 


6 


End of ten months .... 


4.00 


6.00 


3.00 








8 


240 


3 


6 


End of eleven months . 


4.00 


5.00 


3.00 








10 


300 . 


3 


5 


End of twelve months . 


4.00 


4.75 


3.50 








10 


300 


3 


5 



"The data given above are simply a guide to the rules for the feed- 
ing of the average healthy baby; they are only approximate, and not 
intended to be followed in cases of difficult feeding without due con- 
sideration to the individual requirements." 

Quite low dilutions should be given at first, and they should be grad- 
ually increased. Attention should be given not only to digestion but 
to nutrition, the proper estimate of which is determined by regular 
weighing. Sterilization of milk destroys certain ferments, as the rennet 
enzyme, besides protective substances (Ehrlich). 

Treatment of Acute Dyspepsia. — (a) The stomach should be 
washed out, if toxic symptoms are at all marked (Heubner); plain 
water or a 1 to 3,000 resorcin solution should be used, (b) Calomel 
gr. ss and magnesium carbonate gr. j every three hours for about 
three doses, or one dose of castor oil (5ss to j) should be administered, 
(c) The bowel should be flushed with warm water; one pint is sufficient 
in children of one year, or somewhat larger quantities in children two 
years old. (d) Food should be withheld (Czerny) for one or two days, 
and plenty of boiled water only should be given. Albumin water, 
which consists of the whites of two eggs beaten in a pint of water, 



INTESTINAL DISORDERS IN INFANTS 663 

may then be given, and thin arrow-root water, beef juice, and pepton- 
ized milk, may gradually be administered until the green color of the 
stools changes to a normal yellow-brown, (e) Other medication is 
usually superfluous. Lesage recommends that lactic acid be given for 
alkaline green stools, 3j of a two percent, solution (p.c). Resorcin 
£ grain and dilute hydrochloric acid tt# v may be given after meals. 

Treatment of (Dominating) Enteritis. — If the case is seen in the 
early stages, a calomel purge should be administered, and the stomach 
washed out; and in all cases feeding must be suspended as outlined 
above. The child should have plenty of boiled water, and cool appli- 
cations to the skin are indicated unless the extremities are blue and 
cool. Tannigen or tannalbin may be given in relatively large doses, 
10 to 15 grains, several times daily, even in the very young, and may 
often be combined with minute doses of calomel (gr. io). As in enter- 
itis of adults, bismuth subnitrate is given in large doses, 5 SS - Bismuth 
salicylate, in doses of J to 1 grain, is also given. If these are ineffective, 
opium (s 1 o grain) may be administered for several doses. 

Treatment of Cholera Infantum. — Food should be withheld. Lav- 
age of the stomach and bowels is ineffective, unless it is done in the 
earliest stages. There are three main indications: (a) fluid must be 
restored to the tissues; this is possible only by subcutaneous saline 
transfusions which support the heart, fill the vessels, stimulate the 
kidneys, and eliminate the toxins; (b) cardiac stimulation, by hypo- 
dermics of strychnine 300 to 500 grain, and by camphor and local 
heat; champagne may be given to quiet the vomiting and support 
the heart ; brandy and whiskey are given in doses like those employed 
in bronchopneumonia (q. v.), though Heubner believes that alcohol 
further injures the intestinal epithelium; and (c) secretion must be 
checked by administration of 5 minims of paregoric every four hours, 
of small enemas of starch and laudanum (10 minims), or, which is 
more effectual, of morphine (too grain for a child one year old). In 
the fortunate cases which rally, nourishment can be resumed only 
with the greatest caution. The serum treatment is of uncertain value. 

The Treatment of (Dominating) Colitis. — This is much like that 
of dysentery, and includes the measures above indicated. Flushings 
with normal salt solution, 1 per cent, tannin or 1 to 1,000 salicylic 
acid may be employed. Tannigen and bismuth should be given freely. 

The Treatment of Chronic Dyspepsia. — Treatment in institutional 
cases begins with nursing; one wet-nurse can nurse several children. 
Lavage of the stomach with two to three ounces of plain warm water, 
normal salt solution, or 1 per cent. Carlsbad salts solution, increases 
the functional activity of the stomach. The extract of mix vomica 
stimulates secretion (gr. io or according to the child's weight). The 
food must be given in the smallest amounts compatible with main- 
tenance of weight and energy. 



664 DISEASES OF THE DIGESTIVE TRACT 



(G). APPENDICITIS. 

Definition. — Appendicitis, the chief abdominal malady, is an inflam- 
mation of the vermiform appendix. 

History. — Fitz in 1886 drew attention to the subject, and coined the 
name. Appendicitis was previously confused with typhlitis, or inflam- 
mation of the csecum; though typhlitis does exist, it is rare, and the 
term "perityphlitis" should be entirely discarded. Our present 
knowledge of appendicitis is largely due to the work of American sur- 
geons, Willard Parker, who first (1867) advocated operation, Sands, 
Bull, McBurney, Keen, Senn, Murphy, Weir, Morton, White, Deaver, 
and many others. 

Etiology. — 1. Predisposing Factors. — (a) The appendix, being a 
functionless vestige of the csecum, is inherently less resistant, (b) Its 
lumen is smallest at its cacal end, which favors retention of foreign 
bodies, promotes microbic growth, and decreases or suspends drainage 
into the bowel, (c) The meso-appendix, which conveys the blood to 
the appendix, is shorter than the appendix, which therefore curls; the 
blood supply is then easily altered by appendiceal oedema and infiltra- 
tion, (d) Foreign bodies and faecal concretions may produce erosions 
which apparently promote microbic access and therefore inflam- 
mation. In J. B. Murphy's series of 2,140 cases, foreign bodies were 
found in about 20 per cent, and fsecal concretions in 38 per cent. J. F. 
Mitchell found foreign bodies in 7 per cent, of 1,400 cases of appendi- 
citis, and Louis J. Mitchell in 1,600 autopsies found them in about 
1 per cent. Foreign bodies include seeds, capsules, gall-stones, pins, 
nails, shot, fish-bones, etc. {e) Age — Over 50 per cent, of the cases 
occur in persons under twenty years of age, and 30 per cent, in those 
between twenty and thirty. It is rare in infancy, and with advancing 
years obliteration and atrophy lessen its frequency. (/) Sex — Males 
constitute about 80 per cent, of cases; in women it is thought that 
an extra blood supply from the ovary lessens the results of infection, 
though this supposition is disputed, and Murphy's large series shows 
but a slight preponderance in males, (g) Other factors are trauma 
and severe exertion, which are causal in a small number of cases; 
exposure, which is a frequently alleged factor; and enteritis, which 
is seldom a conspicuous prodrome, whence errors in diet are of no 
etiological importance. 

2. Bacteriology. — The colon bacillus is the most frequent cause, 
and is found in 80 per cent, of cases, though probably in some of them 
it has overgrown some other causal organism. Next is the staphylo- 
coccus, the virulent streptococcus, then the pneumococcus, proteus, 
and pyocyaneus. Less frequently the typhoid, tubercle, influenza, or 
actinomycosis organisms are found; Fitz found 5 typhoid perforations 
of the appendix, and Fen wick in a collection of 2,000 cases of phthisis 
recorded 56 per cent, of tuberculous ulcerations in the bowel, of which 
but 0.8 per cent, were in the appendix. 



APPENDICITIS 665 

Symptomatology and Pathology. — 1. The Early Clinical Course. — 
The onset is precipitate, is without prodromes in most cases, and is 
characterized by the four main symptoms upon the sequence of which 
Murphy has placed especial stress, (a) Sudden severe abdominal pain, 
the intensity of which ranges between colic and agony, is nearly always 
due to acute retention within the appendix caused by the occlusion of 
the caecal end, and resembles the pain of retention in acute otitis media. 
It is felt over the right lower abdominal quadrant or over the pit of the 
stomach, and may even radiate along the genitocrural nerve to the 
testis, which is sometimes retracted. Reaching its greatest severity in 
a few hours, the pain persists until the pressure of the pus is relieved, 
which is accomplished by drainage into the bowel, perforation, or 
gangrene. Sudden relief from pain is most ominous, as it often indi- 
cates gangrene. (b) Nausea and vomiting result reflexly from occlu- 
sion and follow within a few hours after the pain, (c) Abdominal 
tenderness soon develops, is rather general at first, and is often associated 
with a cutaneous hyperesthesia (Sherrin), which covers like half a 
girdle the right lower abdomen from the spine to the mid-line. The 
right rectus muscle resists palpation. A little later the general tender- 
ness disappears, leaving well-localized tenderness over the appendix; 
this point is almost always in the right lower quadrant of the abdomen, 
at McBurney's point (about two inches from the anterior superior iliac 
spine in a line drawn between it and the navel), or a little below it in 
adults or above it in children; less frequently the tender point may 
be found in the loin, in the pelvis (5 per cent.), near the bladder, 
rectum, or uterus on rectal or vaginal examination, near the gall- 
bladder, or very exceptionally on the left side of the abdomen, or in 
hernial sacs, all of which correspond to possible variations in appendic- 
ular location. Pressure with the hand on the left half of the abdomen 
causes pain in the right side when the pressure is relieved. Palpation 
must be made gently, lest rupture occur. In the early stage of 
appendicitis it sometimes seems as though a tumor could be felt, 
though it is usually only the contraction of the abdominal muscle. 
(d) Fever is almost invariably present in the early stage of acute forms, 
and develops in a few hours to a day, according to the severity of the 
infection. An initial chill is rare. The temperature rises to 101°-102° 
and even higher in some virulent types or in children. It signifies 
septic absorption, and may cease suddenly in gangrene or gradually 
in rupture, and may slowly recur from extension. It does not signify 
cessation or absence of pus formation, as abscess or peritonitis may 
co-exist with low temperature. There may be other early symptoms. 
The pulse usually follows the temperature curve, though the author 
has seen it remain normal in cases of extensive early gangrene. The 
leukocyte count runs parallel with the fever, and often — though not 
always — measures the sepsis; leukocytosis may amount to 12,000, 
25,000, or even 50,000, but no confident reliance can be placed on its 
absence as an assuring sign nor on its presence as an indication for 
operation. Constipation is present in most cases. The urine is often 



666 



DISEASES OF THE DIGESTIVE TRACT 



febrile, scanty, and usually contains indican and sometimes albumin; 
dysuria may result from appendicitis in the pelvis. Profuse bowel 
hemorrhage has been recorded. In Dieulafoy's toxaemic type toxaemia 
may obscure the local symptoms. 

2. The Later Clinical Course. — (a) The inflammation subsides 
gradually by drainage into the caecum. Though the inflammation may 
be very circumscribed, the appendix rarely returns to a completely 



Fig. 37. 



Fig. 41. 




Fig. 38. 





Fig. 39. 



Fig. 42. 





Fig. 43. 



Fig. 40. 




Figs. 37 and 38. Obliterating appendicitis. Fig. 39. Obliterating appendicitis, with distal enlarge- 
ment. Fig. 40. Obliterating appendicitis (at R.) , with calculi (C). Fig. 41. Appendicitis with 
bending, obliteration and distal distention. Fig. 42. Appendicitis with curling around its 
mesentery. Fig. 43. Strangulation by a band. Fig. 44. Calculous obstruction. (Dieulafoy.) 



normal condition; it suffers necrosis and ulceration from microbes, 
from faecal concretions, or both, which leave the appendix infiltrated, 
thickened, rigid and more or less constricted at one or more points. 
The mucous membrane may be wholly substituted by granulation 



APPENDICITIS 667 

tissue. Sometimes the lumen is entirely obliterated (appendicitis 
obliterans). Occlusion at its intestinal end causes a cyst-like swelling 
as large as the thumb or even as a sausage. Adhesions to the abdom- 
inal wall and gut are common, (b) After a few days a localized peri- 
tonize abscess very frequently forms, usually over the psoas muscle 
at the angle between the ileum and caecum, but occasionally over the 
unusual localization of the appendix (v.s. under Pain). The appendix 
perforates, generally near its middle point at the mesenteric attach- 
ment, from necrosis or gangrene, and a localized abscess of yellow, 
thick, offensive pus forms; when the abscess is well demarked, the 
pain, fever, and pulse rate decrease. A well-defined tumor may develop, 
over which no peristalsis occurs; dulness or tympany are elicited 
according to the depth of the tumor or its fluid or gaseous contents; 
fluctuation is present only in very large abscesses; the tumor in 
infections due to the colon bacillus consists more largely of infiltration 
than of pus. In the incised abscess the green or black and totally 
gangrenous appendix may be seen, or it may be difficult to find. The 
abscess may form without any symptoms other than those of the onset. 
The result of the abscess may vary greatly : (i) it may rupture into the 
intestine which forms its wall (2 per cent.), and may possibly carry 
the appendix with it; (ii) it may rupture into the urinary tract, of 
which cases nearly one-half are fatal; (iii) it may cause thrombo- 
phlebitis purulenta, and any or all of the manifestations of septico- 
pyemia may follow, as secondary fever, suppurative pylephlebitis, 
liver abscess, subphrenic abscess, and vomiting of blood; (iv) it may 
rupture into the retroperitoneal tissue, which is followed by high 
temperature; and all possible extensions may occur, as into the groin, 
the scrotum with external rupture, the pelvis, the pararenal tissue, the 
pleura (84 per cent, are right-sided), the lung, gluteal region, back, 
hip joint, etc. ; and (v) it may rupture into the free peritoneal cavity, 
(c) The third cardinal issue is diffuse septic peritonitis, which is recog- 
nized by all its unfortunate and unmistakable symptoms; these are 
a sudden fall of temperature followed by a secondary fever, diffuse 
replacing localized tenderness and rigidity, sudden hyperleukocytosis, 
persistent projectile vomiting, rapid pulse, Hippocratic facies, and 
collapse from profound intoxication. It most often follows the local- 
ized abscess, but may occur directly after a gangrene which is so 
sudden as to allow of no protective adhesions, or after perforation 
from a foreign body in the appendix without infection; the latter 
occurs in about 1 per cent, of cases, according to Murphy. This 
writer distinguishes variations due to the type of infecting organism: 
(i) The staphylococcic peritonitis which produces generally but little 
pus, or, if any, a seropurulent fluid; it forms a plastic lymph which 
prevents absorption for a short time, but, as the peritoneum becomes 
abraded, leads to intoxication; this is evidenced by collapse, an 
anxious expression, and by diarrhoea, (ii) The streptococcic form, 
which produces no pus, but causes a granular, blistered, dry peritonitis, 
which is quickly followed by rapid pulse, talkative delirium, and tym- 



668 DISEASES OF THE DIGESTIVE TRACT 

pany. (iii) Colon infection, which produces an abundant, creamy, 
thick, offensive pus, and slowly causes death after great depression, 
low, muttering delirium, somnolence, and low arterial pressure. 

3. The More Remote Sequences. — Intestinal strangulation by adhe- 
sions, deformity, and traction from chronic changes in the appendix, 
and intractable intestinal, neurasthenic, and nutritional disturbances, 
may result from chronic appendicitis. 

In children the onset is usually very abrupt; the vomiting is repeated, 
the pain is greater, the appendix is more often palpable, diarrhoea is 
more common, and the percentage is greater (than in adults) of diffuse 
peritonitis, probably because the omentum is less able to envelop the 
appendix. In aged persons gangrene is more frequent than it is in 
youth or middle life. 

Diagnosis. — The diagnosis depends on the four cardinal symptoms 
of onset, in the sequence named; viz., pain, nausea or vomiting, 
abdominal tenderness, and temperature (Murphy), followed by leu- 
kocytosis and the other secondary manifestations, and by the develop- 
ments of the later course, as circumscribed abscess or diffuse peritonitis. 
If all these symptoms are considered separately, an analysis is necessary 
of every abdominal lesion causing pain alone, vomiting alone, tem- 
perature, sensitiveness, abscess, tumor, disease in the right lower abdom- 
inal quadrangle, perforation, or peritonitis. While the existence of an 
acute typhlitis cannot be questioned, it is very rare and should seldom 
receive any consideration. 

Pain occurs in gall-stones, renal calculi, tabetic crises, internal 
incarcerated hernias, epigastric hernia, intussusception, gastric or 
duodenal ulcer, tuberculous peritonitis, stone or torsion of the ureter 
(DietFs crisis in floating kidney), uraemia, colica mucosa, acute pan- 
creatitis, the crises of angioneurotic oedema, pelvic peritonitis, rupture 
of extra-uterine pregnancy, twisted pedicles (ovarian tumors), pyosal- 
pinx, dysmenorrhoea, and the reflected pain of vertebral disease, 
pleurisy, and pneumonia. Fever in typhoid precedes the local symp- 
toms. These affections, as well as gravitating abscesses, infected 
urachus, lesions of the abdominal wall, cancer, hysteria, and hypo- 
chondriacal fear of appendicitis, are almost invariably excluded by 
regarding the sequence of symptoms and by a careful general exami- 
nation. In appendicitis larvata (Ewald), pain is slight or absent, 
and there may be diarrhoea; the thickened sensitive appendix is often 
palpable. 

Exploratory puncture is absolutely contra-indicated. 

Prognosis. — The prognosis is most uncertain, because (a) there is no 
safe criterion for early diagnosis of the type; (6) the symptoms and 
signs are not proportionate to the actual lesions — e. g., light cases clini- 
cally may prove to be the most severe anatomically; (c) apparent 
improvement to the experienced observer is often only the onset of 
alarming complications, which are in reality less complications than 
essential parts of the disease; Dieulafoy well calls them "treacherous 
lulls" (accalmies traitresses); (d) though appendicitis often subsides 



APPENDICITIS 669 

clinically, recovery is seldom complete anatomically, whence recurrence 
(chronic, relapsing, or residual appendicitis) often occurs in a more 
severe form in 24 per cent. (Hawkins) to 44 per cent, of cases (Fitz). 
Treatment. — Cases of appendicitis may recover, temporarily (70 to 
80 per cent, or perhaps more), but it is impossible to predict which ones 
will do so. Personal prejudice was formerly against early, frequent, -or 
universal operative treatment as advocated by many, as Deaver, 
Murphy, Holmes, and others. After testing and seeing tested the so- 
called medical treatment, consisting of rest, starvation, laxatives, and 
other placebos, and seeing gangrene, peritonitis with low temperature, 
and even death, occur in "mild" cases, the conviction is inevitable that 
appendicitis is always surgical, regardless of type, time, or tendencies, 
and a surgeon should at once be associated with the internist or prac- 
titioner in every case. Medical treatment is out of date and recovery 
under it is due to good fortune alone. The so-called indications for 
operation are too often signs of irreparable damage. Of course the 
results of operation depend upon the experience of the operator. 
Though this is not the place for discussion of technique, or of the 
indication for simple drainage or appendicectomy, the following points 
may be given : (a) Early operation within one to two days of onset is 
attended by the least danger, (b) Many operators dislike to operate 
between the second and eighth days or other arbitrary limits, but this 
position implies that the clinician can diagnosticate the anatomical 
changes which are present; gangrene, thrombophlebitis, imminent 
rupture, etc., cannot be excluded; in this period simple drainage is 
indicated — possibly, too, appendicectomy, if the appendix obtrudes in 
the field of incision; lavage, exploration, and protracted operation, are 
dangerous, (c) In later cases, when there is apparent regression, treat- 
ment may be more conservative; complete demarkation may be waited 
for, but even in such cases thrombophlebitis or rupture into the general 
peritoneum may intervene, (d) In cases of diffuse peritonitis incision 
and simple drainage are indicated unless the patient is moribund. The 
patient is placed in the semi-sitting posture (Fowler) and given frequent 
or constant normal salt enemas (Murphy). Many cases recover (see 
Peritonitis), (e) After the attack — Murphy's reasons for operation 
are: "First, after an attack of appendicitis, the patient is prone to 
recurrence; second, upward of 60 per cent, of the cases operated on 
by me in the intermediate stage had had more than one attack; third, 
in the large proportion of the cases in which there was only incision 
and drainage of the abscess (which was a procedure frequently recorded 
by me in my first three hundred cases) the attacks recurred (in one 
patient I drained a peri-appendical abscess on three different occasions, 
always with severe sepsis, before I succeeded in inducing the patient to 
come in between attacks to have the appendix removed); fourth, the 
pathological changes, such as adhesions, flexions, and stenosis, follow- 
ing a primary attack, very much favor a recurrence; fifth, even if there 
were no danger of recurrence of the inflammatory conditions, the adhe- 
sions, fixations, stenoses, flexions, and retentions in the appendix, 



670 DISEASES OF THE DIGESTIVE TRACT 

produce sufficient disturbance of the digestive tract to necessitate an 
operation for their prevention; sixth, recurrent infections are practically 
as dangerous as primary attacks (one patient died in the seventh attack) ; 
seventh, the appendix can be removed without danger." Dennis states 
that under medical treatment the mortality is 16 per cent., relapses 
occur in 30 percent., and diffuse peritonitis causes 100 per cent., mortal- 
ity; under surgical treatment 4 per cent, die, there are no relapses, and 
30 per cent, of cases of peritonitis recover. 



(H). INTESTINAL OBSTRUCTION. 

Etiology. — Obstruction of the bowels may be due: (i) to intus- 
susception, the most frequent cause, which is due to invagination of one 
part of the bowel into another; (ii) to strangulation, which ranks next; 
(iii) to twists (volvulus) and knots; (iv) to strictures; (v) to tumors; 
(vi) to foreign bodies; (vii) to dynamic (paralytic and spastic) 
obstruction. The figures quoted below are from Fitz's series of 295 
cases, Leichtenstern's 1,134 cases and Treves' series. 



I. Intussusception. (Invagination.) 

This is the most frequent form (30 to 40 per cent.) of acute obstruc- 
tion. The external part (the intussuscipiens or vagina) receives into it 
the intestine just above (the intussusceptum or invaginatum). The 
actual cause is unknown; it develops in perfect health, in various acute 
and chronic affections, in tumors and strictures of the gut, in diarrhoea 
and other functional and intestinal disorders, and in contusion. Two 
theories are advanced: (a) that the gut is spastically contracted 
(Nothnagel) and therefore enters the gut below, and (b) that the gut 
below is paretic (Leichtenstern). The author saw a marked case in 
lead-colic, which recovered under operation by Van Hook. In acute 
intussusception 50 per cent, occurs under ten years of age (Leichten- 
stern and Fitz) ; Wiggin in 103 cases found 50 per cent, in the fourth, 
fifth, and sixth month of life. In chronic intussusception 50 per cent, 
occurs in persons between twenty and forty years of age; 66 per cent, 
occurs in males. Pathologically only the vital or inflammatory form 
is of clinical importance, in which the mesentery and its vessels are also 
invaginated; the " agonal" form occurs during the death agony, 
chiefly in children, in the small gut, is often multiple, and does not 
involve the mesentery. The vital form is usually single, descending 
(in 99 per cent.), and complete; incomplete forms may result from 
polyps or other tumors, usually benign, which drag down the gut. 
There are three main forms : (a) the enteric, the small gut invaginating 
into the small gut, 30 per cent. ; (b) the ileocecal, the small gut enter- 
ing the large gut, 52 per cent. Leichtenstern (75 per cent. Fitz and 89 
per cent. Wiggin); and (c) the colonic, the large gut invaginating into 



STRANGULATION T 671 

the large gut (18 per cent.), which includes the colon invaginating into 
the rectum; in rare cases a Meckel's diverticulum may invaginate into 
the small gut. 

Symptoms. — (a) There is sudden, severe, reflex pain, which is 
usually umbilical in children but sometimes occurs elsewhere in adults, 
is continuous or intermittent, or paroxysmal in chronic forms of intus- 
susception, (b) Early reflex vomiting may occur in children, though 
in adults it is less frequent than in other forms of obstruction ; the later 
vomiting is seldom fsecal (13 per cent., Fitz); vomiting is more marked 
in high than in low invagination and depends considerably on the 
degree of mesenteric invagination and its necessary vascular dis- 
turbance, (c) The stools are characteristic, showing blood and mucus 
in 80 per cent, of acute and in 50 per cent, of chronic cases; in 108 
cases collected by Hare and Martin, blood was present in the stools in 
104; the movements may not stop at once but only after several evacu- 
ations. Their evacuation is attended by severe tenesmus (50 per cent.), 
especially in the young, (d) A sausage- or egg-like movable firm tumor 
(50 per cent. Leichtenstern, 61 per cent. Fitz) may be palpated, most 
often over the ascending or transverse colon, sometimes by the rectum 
or vagina, and is occasionally visible at the anus, where it has been 
mistaken for prolapse or polyp and has been extirpated. It is most 
common in children, and in the ileocecal form. According to Treves 
it is nearly always to be felt during paroxysms of pain, (e) Meteorism 
and a depression in the right flank or ileocecal region are infrequent. 

Issues. — Peritonitis results in 50 per cent, of acute and nearly 100 
per cent, of chronic cases; perforation occurs in chronic (15 per cent.) 
more often than in acute cases; sloughing off of the gangrenous bowel 
occurs in 42 per cent, of adult cases, and seldom in children ; in Cruveil- 
hier's case three yards of dead gut were discharged. Spontaneous 
reposition and fistula are very uncommon. 



II. Strangulation. 

This causes 35 to 38 per cent, of intestinal obstructions. Its mech- 
anisms are innumerable; it is generally due to bands, or isolated 
peritonitic adhesions; Meckel's diverticulum, the remains of the 
omphalomesenteric duct, which lies within a yard of the ileocecal 
valve and is sometimes continuous as a cord to the navel, has caused 
strangulation in 183 cases (Hilgenreiner, 1902); adhesions from pre- 
vious peritonitis, appendicitis, or salpingitis; omental strands forming 
bands under which the gut is caught; holding of the gut in abnormal 
positions; and binding of coils to each other. Incarceration may occur 
when there are congenital or acquired orifices and clefts in the omentum 
or mesentery or under the suspensory ligament of the liver, ligamentum 
teres, or ligamentum latum uteri. Hernias include strangulations in 
the more common locations (femoral, inguinal, umbilical), or in the less 
frequent types as the obturator, sciatic, lumbar, intersigmoid, retrocse- 



672 DISEASES OF THE DIGESTIVE TRACT 

eal (Rieux), foramen of Win slow, duodenojejunal (Treitz's retro- 
peritoneal form), or diaphragmatic. Seventy per cent, of cases occurs 
in males, 40 per cent, between fifteen and thirty years of age, 90 per 
cent, in the small intestine, 67 per cent, in the right iliac fossa, and 
83 per cent, in the lower abdomen (Fitz). 

Symptoms. — -The symptoms are usually acute and urgent, (a) 
Early reflex vomiting, from shock, voiding in succession the gastric 
contents, bile, and faecal matter which usually consists of yellow, 
brown, or black fluid or very rarely solid faeces, is strongly indicative of 
organic strangulation; vomiting usually lasts from the beginning to 
the end of the disease; retching results from nervous reflex irritation. 
(b) There is early severe reflex pain, which is greatest at the navel and 
lasts until collapse, peritonitis, or paralysis of the gut develops, (c) 
Collapse, with Hippocratic expression, weak pulse, and hurried 
breathing, which resembles the condition in cholera, results reflexly 
and may occur early from the disturbed local circulation in the gut, or 
later from peritonitis, (d) Complete sudden stoppage of the bowels may 
result in which no faeces nor flatus can pass; some faeces from the lower 
gut may pass after enemata, but no gas. Meteorism of two kinds 
occurs — (i) the static variety in which gas accumulates in loops above 
the obstruction, and (ii) the local variety, in which the strangulated 
loop becomes distended, chiefly because its circulation is impaired; it 
may be seen or felt as an immovable tense mass, showing no peristalsis 
and corresponding to the thick, cedematous, hemorrhagically infiltrated 
and finally gangrenous gut. (e) The urine is decreased, because of 
the vomiting, lack of food, and nervous collapse ; it contains indican if 
the obstruction lies in the small gut, and is tested by treating with 
Obermeyer's solution (2 pro mille solution of ferric chloride in con- 
centrated hydrochloric acid) and shaking with chloroform. Sometimes 
casts, albumin, or even hemorrhagic nephritis, are observed. (/) 
Strangulation in some cases may be found in the usual or accessible 
hernia locations. 

Diaphragmatic hernia was first diagnosticated by Leichtenstern 
(1874); it is left-sided in 88 per cent., is congenital or acquired (from 
trauma especially), and is recognized in but 3 per cent, of the reported 
cases ; its signs closely resemble those of pneumothorax (see Diagno- 
sis of Pneumothorax) . 

In strangulation and other acute obstructions (v.i.) the mucosa in 
the occluded area may become eroded, more easily penetrated by 
bacteria, ulcerated, and hemorrhagically infarcted, leading to necrosis, 
perforation, and peritonitis. 

III. Twists (Volvulus) and Knots. 

Volvulus is a twisting of the intestine, which in nearly all cases 
occurs around the mesenteric axis; twisting of the gut on itself is rare; 
volvulus occurs in 14 per cent, of obstructions (Fitz); 68 per cent, of 



STRICTURE (ENTEROSTENOSIS) 673 

the cases are males, usually between forty and sixty years old ; it occurs 
in the sigmoid flexure in 66 per cent. (Leichtenstern), less frequently 
in the csecum (75 cases collected in 1905 by Corner and Sargent), colon 
ascendens, and small gut, and then especially when the large and small 
intestines have a small mesentery; only three cases of volvulus of the 
stomach are recorded. The predisposing causes of volvulus are a 
vegetable diet (said to explain its frequency in Russian peasants), 
persistent constipation, a long sigmoid flexure with a long but narrow 
mesentery, and mesenteritis. The twist may occur through 180 to 360 
degrees or more. 

Symptoms. — The symptoms closely resemble those of the forms 
described, especially when knots form between two coils of the small 
intestine. In volvulus of the sigmoid there is pain and vomiting, 
which is less marked than in strangulation or invagination and is 
seldom fsecal; the local meteorism is more pronounced than in any other 
type of obstruction, for the huge coil of the obstructed gut passes up- 
ward, possibly to the right, in extreme cases pushes up the diaphragm 
to the third or fourth ribs, and seldom shows any peristalsis, which its 
disturbed circulation prevents. But little water can be injected into 
the rectum. Hemorrhagic peritoneal exudate is common. 



IV. Strictures (Enterostenosis). 

Strictures more often cause chronic than acute obstruction, (a) 
Congenital stricture is even rarer than the rare congenital atresia 
(imperforate anus, ileocecal, duodenal, or sigmoid atresia), (b) Cica- 
tricial stricture results from healing of tuberculous, syphilitic, dysen- 
teric, duodenal, and, very rarely, typhoid ulcers. In 1904 Arbuson 
collated 129 cases of tuberculous stricture, (c) Annular cancer, (d) 
compression by various organs or tumors (80 per cent, of which are 
pelvic), and (e) traction, are other causes. (/) Inflammatory hyper- 
trophy of the mucosa and muscularis is exceedingly uncommon. 

Symptoms. — The symptoms are those of chronic obstruction, and 
vary with the location of the stenosis. (I) Stenosis of the small intes- 
tine may occur (a) above the duodenal papilla, as a result of gall- 
stones or duodenal ulcer, and resembles pyloric stenosis, from which 
differentiation is practically impossible; it may occur (b) in the duo- 
denum below the papilla, as a result of gall-bladder adhesions, duo- 
denal ulcer, tumors, or pancreatic disease (acute pancreatitis, tumor, 
cyst); icterus is frequent, as well as vomiting of bile and pancreatic 
juice (which digests starch and fibrin in an alkaline medium) ; other 
symptoms are dilatation of the stomach, pale stools, very slight ab- 
dominal meteorism except over the epigastrium, and the absence of 
indicanuria. (c) Jejuno-ileac stricture may result from healed ulcers, 
inflammation in replaced hernias, and adhesions to the internal geni- 
talia; the ulcer stricture may be multiple, as many as twelve being 
recorded in one case; it is remarkable that extreme stenosis may cause 

43 



674 DISEASES OF THE DIGESTIVE TRACT 

no symptoms. There is constipation, which sometimes alternates with 
diarrhoea, colic, meteorism, and visible palpable peristalsis, causing 
"intestinal stiffness" (Nothnagel) until the obstruction is finally over- 
come by the hypertrophied muscle above the stricture, when a gurgling 
sound is sometimes heard. The colon is collapsed. (II) Stricture of 
the large gut is marked by constipation, which is significant when it 
develops rapidly in a person not previously constipated or when 
cathartics have no effect in constipated individuals; by paroxysmal or 
colicky pain, even more than in stricture of the small gut, because the 
stools are harder; eventually by nausea and vomiting, which are suc- 
cessively gastric, bilious, and stercoraceous ; by meteorism along the 
colon and in the lumbar region behind, which it is usually dull; by 
increased, even tetanic, peristalsis in the intestinal coils above the 
stricture, which possesses a distinct localizing value; and by the 
evacuations which may be ribbon-like or sheep-stools, and which are 
often diagnostically overestimated, for they may occur in tumors, 
starvation, colica mucosa, and spastic constipation; they are positive 
neither by their absence nor presence. 

V. Tumors (see page 677). 

VI. Foreign Bodies. 

Foreign bodies caused obstruction in 12 per cent, of Fitz's series. 
(a) Gall-stones — of which 250 obstruction cases are on record — lodge 
chiefly in the upper duodenum or lower ileum, ulcerate through the gall- 
bladder into the duodenum or less often through the colon, or com- 
press the duodenum through a dilated pouch of the cystic duct. In a 
surprisingly small per cent, is there a history of colic (19 per cent.) or 
of icterus. Collapse is usually not marked, a tumor is seldom felt, 
and the constipation is often but relative; indeed, diarrhoea may 
occur, (b) Fwcal masses are far more common than statistics show, 
and form the chief obstruction of the large gut. The writer saw a 
case of acute absolute obstruction develop after a Thanksgiving din- 
ner ; there was faecal vomiting and severe collapse ; a mass of not 
particularly hard food, measuring two inches in diameter, was found; 
recovery occurred, though the bowel was partly necrotic. They are 
found especially in the sigmoid (see Constipation), (c) Enteroliths 
are not common. They form slowly of phosphates, usually with an 
organic nucleus; sometimes they are constituted of bismuth, chalk, 
iron, or magnesia. They measure an inch to nine inches in diameter, 
and in one instance an enterolith weighed four pounds. Though most 
common in the large intestine, they may develop in diverticula of the 
small intestine, (d) Hair tumors, twisted masses of ascarides, fruit 
seeds, oatmeal husks (especially in Scotland), stones, and foreign bodies 
(in children or insane subjects), are possible causes. 



DYNAMIC ILEUS 



675 



VII. Dynamic Ileus. 

The above causes are mechanical. Another form of acute obstruc- 
tion is distinguished, namely, dynamic ileus (paralytic or spastic 
obstruction). Under this topic may be included obstruction follow- 
ing mesenteric embolism, trauma, abdominal operations, or inflam- 
mation in an undescended testicle; they are largely but not absolutely 
associated with acute peritonitis. Spasmodic obstruction may develop 
in rare cases without cause, or in neurotics, in gall-stone occlusion, 
ulceration, and intestinal crisis of tabes. It rarely produces faecal 
vomiting; Bregmann ;(1901) found in the literature 20 cases of 
hysterical ileus. 

Diagnosis. — 1. Of the Factjof Obstruction. — The symptoms are 
generally unmistakable, and consist of constipation, cessation of flatus, 
distention (particularly the local form), compensatory peristalsis (hyper- 
trophy), and frequently general reaction (collapse). The hernial sites, 
the rectum, and the vagina, must always be carefully examined. 

2. Of the Location. — The uncertainties of diagnosis of location are 
manifold, but the following table brings out some of the leading cri- 
teria : 

. Of the Large Intestine. 

Later and less impressed. 



Obstruction of the Small. 

General Condition — Earlier and more 
profoundly impressed (reflexly) by 
toxaemia and peritonitis. 

Symptoms more marked, more stormy 
onset, more vomiting (both reflex 
and faecal), more pain. 



Indicanuria— -Develops early, and to 
marked degree. 

Urine — Much decreased. 



Signs more marked, as meteorism along 
colon (later becoming general), less 
water can be injected, more peristaltic 
effort and palpable rigid coils, more 
results by rectal or vaginal examina- 
tion, more tenesmus. 

Develops later or not at all (also pres- 
ent in cancer and peritonitis). 

little decreased. 



3. Of Its Nature. — Only the broadest probabilities may be considered, 
(a) It is practically impossible to recognize obstruction by bands, 
adhesions, Meckel's diverticulum, clefts, and internal hernias (except 
diaphragmatic), (b) Invagination is not only the most frequent but 
also the most characteristic form, because of its sudden onset (in 
children), severe (intermittent) pain, tumor, bloody stool (very rare in 
hernias replaced by operation or taxis, in strangulation, volvulus or 
gall-stones), tenesmus, results of rectal palpation, and the exfoliation 
of dead intestine, (c) Strangulation is next in frequency, and is differ- 
entiated from coprostasis, stone occlusion, compression, stenosis, and 
tumors, by its more marked and earlier collapse, its more severe initial 
pain and vomiting, its greater local meteorism, and more frequent 
hemorrhagic peritoneal effusion, (d) Volvulus is suggested by the 



676 DISEASES OF THE DIGESTIVE TRACT 

advanced age of the patient, constipation, relatively slower onset and 
course, infrequent faecal vomiting, and the meteorism, which is greater 
than in any other form and is accompanied by little peristalsis. The 
small amount of fluid which can be injected, the frequent hemorrhagic 
peritoneal fluid, the tenesmus, and the slightness, lateness or absence of 
indicanuria, are also suggestive, (e) Gall-stones often give no positive 
symptoms; in some instances the lack of shock, of increased pulse, and 
of meteorism, and the paradoxical intermittent release of flatus and 
faeces, may be suggestive. In no other type is faecal vomiting, combined 
with the passage of flatus and faeces, so common. 

4. Differentiation. — Confusion with flatulent colic, gall- or kidney- 
stones, and incarceration of the kidney, uterus, or testis, is avoided 
because in intestinal obstruction there is rapid stoppage of the bowels ; 
the author saw one case of lead-colic with intussusception. The possi- 
bility of acute pancreatitis must be considered. Peritonitis is charac- 
terized by early fever, early diffuse tenderness, meteorism, cessation of 
peristalsis, board-like abdominal rigidity, often by fluid in the perito- 
neum, late collapse, late faecal vomiting, later and less complete ob- 
struction, and by frequent singultus. 

Treatment. — In stenosis, which is typified by ulcer cicatrices, a con- 
centrated fluid or semi-fluid diet should be given, and thorough masti- 
cation of solid food and avoidance of coarse food, or food with chaff, 
skins, stone, or gristle, should be insisted on. Cathartics are to be 
avoided, and the bowels should be moved with enemata of oil or water. 

Thiosinamin has been recommended to dissolve cicatricial stenosis : 

Thiosinamin 5j. 

Glycerini 5iij. 

Acoholis diluti 5vj. 

M. et S. — Inject 8 to 15 drops subcutaneously once daily. 

Operative measures may be instituted for foreign bodies or for malig- 
nancy, in which case the outlook is best in lesions of the colon and 
ileum. 

1. Medical Treatment of Obstruction. — In every case the physician 
should at once divide the responsibility with a surgeon. In acute cases, 
especially in the small intestines, food causes aggravation. Early gastric 
lavage affords some, though transitory, relief. The possibility of 
chronic f&cal obstruction should be first eliminated by colonic flushings, 
given with the patient's head down or body inverted; hard desiccated 
faeces must be dug out with the finger, with frequent enemata to bring 
away fragments; in colonic injections a soft tube cannot be passed 
easily above the sigmoid, and hard tubes may cause perforation. High 
enemata and colonic inflation with air occasionally reduce volvulus and 
intussusception. Laxatives, massage, and puncture of the gut with an 
exploring needle, are always contra-indicated. Opium is useful in the 
early stage to relieve shock; in moderate dosage it does not produce 
intestinal paresis. Stimulants hypodermatically are frequently indi- 
cated. The use of atropine (Theden, 1788) has been recently revived, 



INTESTINAL TUMORS 677 

especially by Batsch (1900) ; some cases are relieved by it, but danger- 
ously large doses are necessary. 

2. Operative Treatment. — Medical treatment of strangulation, 
intussusception, or volvulus, is of little value. A most convincing 
statistical argument for early operation is Naunyn's series of 288 cases, 
in which 75 per cent, of recoveries was obtained by operation in the 
first two days, while each successive day lowered the patient 's chances 
to 40 per cent., 30 per cent., etc. Obalinski (110 cases) reports 35 per 
cent, recoveries, Treves (155 cases) 54 per cent., and Kocher in his 
earlier experience 38 per cent, and later 70 per cent. (96 cases of his 
own). Much depends on the physiological resistance of the patient. 
In intussusception Gibson's figures (239 cases) give 53 per cent, as the 
average mortality from operation, being 39 per cent, for operations in 
the first two days, and increasing with each day of postponement; it 
was 82 per cent, in children under three months of age; Rydygier's 
mortality in chronic forms was but 24 per cent. Forty per cent, of adults 
and 80 per cent, of children die under medical treatment (Leicht en- 
stern). In 100 cases of intussusception in children 63 per cent, of 
operated recoveries are reported by Clubbe (1905). Fifty-two per cent, 
of obstruction by gall-stones recover under expectant and 33 per 
cent, under surgical treatment. For the indications and technique of 
resection, anastomosis, enterostomy, colostomy, etc., reference should 
be made to surgical treatises. 



(I). INTESTINAL TUMORS. 

Carcinoma is the only neoplasm of clinical importance. It is esti- 
mated that it constitutes 22 per cent, of all cancers. Its etiology is as 
obscure as that of all cancers. Trauma is seemingly an occasional 
factor and previous ulceration is a predisposing cause. It is most fre- 
quent in males over forty years of age; according to Maydl, 17 per 
cent, occurs in persons between thirty and forty and 14 per cent, in 
those under thirty years of age. 

Pathology. — According to Leube, 80 per cent, occurs in the rectum, 
15 per cent, in the caecum and colon, and 5 per cent, in the small intes- 
tine. Haussmann, in 268 cancers of the bowel (excluding those of 
the rectum), found 91 per cent, in the large and 9 per cent, in the small 
bowel; if figured more in detail, 37 per cent, occurs in the sigmoid, 
18 per cent, in the caecum, 11 in the descending colon, 9 in the trans- 
verse and 8 per cent, in the ascending colon, 8 per cent, in the ileum, 
4 in the splenic and 3 in the hepatic flexure, and 2 per cent, in the 
jejunum. Kanzler (1906) found in the literature, only twenty-five 
cases of cancer in the jejunum and ileum (i. e., in the small intestine ex- 
clusive of the duodenal and ileocecal regions). The sigmoid, splenic 
and hepatic flexures are especially predisposed, probably because 
these sites are more fixed and exposed to irritation. It is usually pri- 
mary, sometimes secondary by contiguity, but very rarely metastatic. 



678 DISEASES OF THE DIGESTIVE TRACT 

Originating in the intestinal glands, it is usually annular in form, and 
causes stenosis and ultimate occlusion of the bowel ; it is less often 
nodular and is very rarely diffuse and flat. Histologically it may be 
an adenocarcinoma (especially when it occurs in the duodenum), 
scirrhus (in the sigmoid), medullary, cylindrical-celled, (in the caecum 
and sigmoid), colloid or flat-celled (in the rectum). Beginning in the 
mucosa, early involvement of the other coats and lymph vessels usually 
occurs, followed by later involvement of the peritoneum and metastasis, 
especially in the liver. (A. O. J. Kelly finds in the literature 49 ap- 
pendiceal cancers.) 

Symptoms. — 1. Disturbance of the Intestinal Function. — (a) There 
is usually constipation, resulting from narrowing of the intestinal lumen ; 
it is most marked in tumors of the large intestine. Ulceration frequently 
causes diarrhoea, (b) The stools are irregular and sometimes assume 
peculiar forms, as band-like or sheep-like stools, to which, however, 
undue importance has been attached, as they occur in inanition, 
starvation, constipation, etc. (c) Blood, mucus, and pus, are common 
in the faeces, though equally frequent in other ulcerations and in enteri- 
tis. The evacuations may be stinking, (d) Fragments of tissue are 
uncommon ; they also occur in dysentery and are diagnostic only when 
showing carcinomatous arrangement of the cells, (e) Pain, due to 
enterostenosis, is usual; it may be sacral when due to sigmoid cancer. 
(/) Sudden complete occlusion of the bowel may follow previous 
gradual narrowing of the lumen, (g) The lower the tumor in the 
intestinal tract the greater is the tympany and fcecal retention and the 
purer the pus and blood (i.e., the less mixed with the faeces). Above 
the stricture the bowel is dilated (tympany) and its muscle is hyper- 
trophied (visible peristalsis), (h) Indicanuria has much the same 
significance- as it has in intestinal obstruction. 

2. Cachexia and Marasmus. — These, with the above symptoms, are 
most suggestive. 

3. Tumor. — Until a tumor is detected, the symptoms described are 
not diagnostic. It is best felt if the bowel is empty; it may be confused 
with a normal contracted colon, the edge of the ileopsoas, or with faecal 
masses ; it is irregularly oval in clear cases, though in annular forms it 
escapes detection, for it merely constricts the bowel. It is usually 
tender, and is movable or immovable accordingly as the bowel involved 
is naturally free or fixed (incomplete peritoneal investment), or is 
adherent to other structures by adhesions or extension by contiguity. 
Whether free or fixed, the tumor is generally below the navel. Gas 
and fluid are sometimes felt or heard to escape through the stenotic 
point, and distention of the large bowel by introduction per rectum of 
air or fluid may aid in localization of the tumor. If the tumor grows 
from a part of the gut which is movable it may disappear and reap- 
pear from time to time. When no tumor is detected by abdominal 
palpation and inspection, a rectal and vaginal examination should 
always be made. 



INTESTINAL TUMORS 679 

4. Complications. — Complications may first declare the malignancy 
of primarily ambiguous symptoms, as (a) icterus, especially in duo- 
denal cancer; (b) hemorrhage from the bowels; (c) rupture into the 
bladder or vagina, or into the stomach (with faecal vomiting and 
diarrhoea from food entering the colon). 

Diagnosis. — The diagnosis is often difficult, except in cases of rectal 
localization, for latency is common and many symptoms merely 
indicate stenosis without declaring its nature. According to Leube, 
differentiation is required from other movable and immovable tumors : 

1. Movable Tumors. — (a) These may be pyloric, requiring differen- 
tiation from duodenal cancers; the symptoms may be identical, but 
icterus, the presence of free HC1, bile, and pancreatic juice, in the 
stomach are aids in diagnosis. (6) The corset liver, movable spleen 
and kidney will be considered under those topics, (c) Omental and 
mesenteric tumors may be confusing, but they do not produce the same 
enterostenosis. (d) Scybala may co-exist with malignancy; the 
repeated use of enemata and cathartics determines the diagnosis (see 
Constipation). 

2. Immovable Tumors. — (a) Renal and retroperitoneal tumors lie 
beyond the colon (on its inflation) and rarely cause the same degree of 
intestinal obstruction. (6) Encapsulated peritoneal exudate may be 
difficult of diagnosis; the author has seen two chronic appendicitic 
abscesses in individuals over sixty years of age which were diagnos- 
ticated as tumor, were hard on palpation, and which recovered by 
discharging pus into the bowel, (c) Ovarian or uterine tumors are 
less obstructive and are located more in the pelvis, (d) Localized 
inflammatory infiltration of the intestinal wall is distinguished by its 
regressive evolution. Bittorf, particularly, has called attention to cir- 
cumscribed inflammation of the sigmoid flexure and colon. 

Rectal cancer should receive special consideration in diagnosis. It 
is usually annular-, and when developed is rigid, frequently resembles an 
inverted funnel, becoming narrow upward and may even resemble 
a hard cervix uteri. The colloid form extends upward and down- 
ward, is often tubular, and causes much regional invasion. A 
systematic rectal examination — which is unaccountably more often 
neglected than any other simple method of physical examination — 
saves many lamentable errors. The early stricture may yield when 
ulceration develops, and this usually occurs with discharge of blood, 
often ichorous pus, and sometimes malignant tissue. Pain is usually 
but not always present, tenesmus is the rule, and hemorrhoids are very 
suggestive. Cachexia develops with great rapidity, though it is no 
necessary symptom; the author has seen death result from obstruc- 
tion with perfect preservation of color, nutrition, and energy. In- 
toxication symptoms are frequent, as stupor and other evidences of 
brain depression. 

Syphilitic strictures are slower and subject to greater variations than 
those due to cancer; tuberculous ulcers are flatter, softer, and more 
undermined. 



680 DISEASES OF THE DIGESTIVE TRACT 

Cancer in any part of the bowel cannot be clinically differentiated 
from sarcoma, of which Lecene (1904) collected 75 cases involving the 
small bowel; their course is more rapid and they seldom stenose the 
lumen. (Ward [1904] found 34 lipomata recorded.) 

Prognosis. — The prognosis of all forms and locations is bad. Mar- 
asmus, coma carcinomatosum, anasarca, thrombosis, embolism, sec- 
ondary infections, stenosis, or perforation, may be the cause of death. 

Treatment. — Treatment is that of enterostenosis, in regard to diet. 
Opium must inevitably be used toward the end. Operation, either 
palliative (enterostomy, colostomy) or curative (enterectomy), may 
be indicated. In 1896, Wolfler's series of cases of resection resulted in 
a mortality of 54 per cent., as against a death rate of 39 per cent, in 
resection for causes other than malignancy. Hochen egg (1902) in 194 
radical operations, reports a mortality of but 12 per cent., and estimates 
his recoveries at 16 per cent. Czerny (228 operated cases, 1902) reports 
14 per cent, of permanent recoveries. 



(J). ENTEROPTOSIS. 

Enteroptosis is not a disease per se, but only a condition in which the 
abdominal viscera "fall" or prolapse in the abdomen. The stomach 
(gastroptosis), intestine (enteroptosis), colon (coloptosis), or solid 
viscera (splanchnoptosis), as the liver, kidney, or spleen, may be impli- 
cated. The condition is known as Glenard's disease, and Glenard 
referred it to laxness of the hepatocolic ligament. Ewald and others 
combat this view, and explain the transverse rigidity felt in the ab- 
domen not as the colon, but the pancreas, exposed by sinking of 
the intestines. Its exact explanation is still disputed, though whatever 
causes relaxation of the abdominal wall or of the intra-abdominal 
suspensory structures may induce prolapse, as trauma, coughing, loss 
of weight, pregnancy, tumors of the liver, spleen or kidney, spinal 
deformity, and corsets. Seventy-five per cent, of the cases occur in 
women. Stiller maintains that splanchnoptosis is a congenital asthenic 
condition whose most frequent stigma is a floating tenth rib (costa 
fluctnans decima) ; this is found in 80 per cent, of cases. He also speaks 
of a habitus enter optoticus , which somewhat resembles the habitus 
phthisicus; in the normal chest the vertical line drawn from the ensiform 
to the navel is short, compared with the distance from the median line, 
horizontally, to the floating ribs; in the habitus enter optoticus the 
vertical line is much longer and the horizontal line is shorter than 
normal and shorter compared with the vertical line; this habitus is 
considered a congenital predisposing cause, and enteroptosis is the 
resulting acquired disease. The tendency develops the disease, when 
the patient's nutrition suffers. 

Symptoms. — 1. Stomach Findings. — Gastroptosis is characterized 
by falling of the organ to a lower point in the abdomen, whereby both 
its upper and lower limits are abnormally low, the epigastrium is 



ENTEROPTOSIS 681 

flattened, and the hypogastrium is distended. Eichhorst and Einhorn 
find it in 35 per cent, of women and in 5 per cent, of men. Dilatation 
of the stomach is excluded by finding the lesser curvature at a lower 
point than normal, which is determined by inflation with carbon diox- 
ide. In marked gastroptosis the lesser curvature lies near the umbil- 
icus; dilatation and gastroptosis may co-exist. The sharp angle 
formed at the pylorus or duodenum, too, may cause difficulty in gastric 
evacuation. Gastric symptoms may be noted, as anorexia, a sense of 
pressure, eructations, nausea, and gastric or intestinal hyperesthesia, 
or as complications, vomiting, hyperacidity, or motor insufficiency. 
In many cases gastric and other symptoms are entirely lacking. 

2. Intestinal Findings. — Enteroptosis or coloptosis is frequently 
found with gastroptosis. The transverse colon sinks in its central 
segment so as to assume the form of the letter U or V. Constipation, 
sometimes alternating with diarrhoea, and rumblings in the bowel, are 
frequent. 

3. Visceral Findings. — Floating kidney, liver, and spleen, will be 
described separately; in this connection the only necessary comment is 
that floating kidney is neither cause nor effect of gastroptosis or enter- 
optosis, but merely coordinate to a third general causal factor. 

4. Nervous Symptoms. — These occur in 50 per cent, of cases. Many 
subjects are nervous, delicate, slight, and irritable women. The most 
common nervous symptoms are lassitude, depression, a sense of cephalic 
pressure, backache, and other neurasthenic manifestations. The abdom- 
inal aorta frequently throbs with violence. The patient complains 
of a " falling out" sensation. Emaciation, constipation, and anaemia, 
are quite common. 

Treatment. — (a) For the neurasthenic symptoms the treatment 
outlined under neurasthenia (q.v.) is indicated. The diagnosis should 
not be disclosed to the patient, for this initiates, by suggestion, a 
long train of additional symptoms, (b) Increase in weight should be 
sought, by ample feeding and rest in bed, which indication is met by 
the rest cure, (c) Supports to restore and maintain the viscera in their 
normal location often give considerable and immediate relief. The 
direction of the pressure should be upward and inward. Strips of 
adhesive plaster are useful but are uncomfortable, (d) No drugs can 
restore tone to the lax ligaments. Strychnine may be beneficial as a 
general and digestive tonic, (e) Operation, indicated only in cases 
with neurasthenic symptoms; sometimes, however, surgical inter- 
ference is contra-indicated by these very symptoms. Shortening the 
mesentery, resecting parts of the recti muscles, suture of the liver, 
stomach and other organs to fixed tissues, have been performed seem- 
ingly with success, but this procedure can as yet receive no general 
commendation. 



682 DISEASES OF THE DIGESTIVE TRACT 

(K). DILATATION OF THE COLON. 

Colectasia may be classified as follows: (a) Gaseous distention, 
which may occur in acute toxaemias. Fenwick recorded a case so 
marked that death resulted from heart paralysis. The treatment is 
that of tympanites (v. Typhoid and Enteritis), (b) Cases which are 
due to obstruction by fasces, foreign bodies, volvulus, (c) The so-called 
idiopathic colectasia, which occurs in children (in 80 per cent, of cases) 
as a congenital lesion, or in male adults over fifty years. Up to 1904, 
80 cases were published (Kredel). It is also known as Hirschsprung's 
disease, being first described by Hirschsprung, of Copenhagen. Treves 
holds that it is always due to obstruction, though cases without ob- 
struction are noted, as Formad's case, in which there was great hyper- 
trophy of the muscularis without organic stricture; the maximum 
circumference of the colon was 30 inches and its weight with the con- 
tained faeces was 47 pounds. The leading symptoms are obstinate 
constipation and meteorism. Of the reported cases only about 25 
per cent, recovered either under medical treatment or after resection of 
the sigmoid, or colostomy. Death results from marasmus, auto-intoxi- 
cation, intestinal obstruction, perforation, or peritonitis. 

(L). INTESTINAL HEMORRHAGE. 

Etiology. — There are five groups of causes, (a) Abnormal intes- 
tinal contents, as hard faeces, foreign bodies, gall-stones, caustic poisons, 
or parasites (anchylostomum or distomum). (b) Intestinal lesions, as 
ulcerations (dysenteric, tuberculous, duodenal, typhoid, carcinoma- 
tous, polypoid, hemorrhoidal), inflammation, as enteritis senilis, 
toxica, or cathartica; invagination, volvulus, and trauma, (c) General 
affections; cardiac or portal stasis, amyloid disease, infarction of the 
superior mesenteric vessels, inanition, aneurysmal rupture, scurvy, 
uraemia, and cholaemia. (d) Infections, including typhoid, dysentery, 
malaria, yellow fever, syphilis, tuberculosis, septicopyemia, and 
hemorrhagic exanthemata. In the young (melaena neonatorum) 
sepsis is a prominent factor (see Hemorrhagic Diseases of the New- 
born), (e) Blood from the stomach. The blood may be of capillary, 
arterial, or venous origin. 

Symptoms. — The symptoms are: (a) Blood in the fceces. It may be 
obvious or "occult" — i.e., found only microscopically, chemically, or 
spectroscopically. Blood is generally present microscopically a number 
of hours before it is seen by the naked eye. It is usually mixed with 
faeces, and dark, tarry and offensive when it comes from the small gut; 
it may coat the movements and be bright in color when it comes 
from the lower intestine, (b) Acute ancemia may follow profuse hemor- 
rhage; this is evidenced by pallor, syncope, rapid heart, and/ slight 
febrile movement, (c) There are, finally, the symptoms of the causal 
disease, as typhoid or cancer 



PILES 683 

Diagnosis. — The diagnosis of enterorrhagia concerns (a) the de- 
tection of blood, which may be simulated by bismuth or blueberries, 
but its presence is easily established by the red disks, the 
hsematin crystals, the guaiac reaction, and the spectroscopic lines; (b) 
the question whether the blood comes from the bowel or from the 
mouth or stomach; (c) whether it comes from the large or small gut 
(v.s.); and (d) its causes, which are most often hemorrhoids, typhoid, 
dysentery and cancer of the lower bowel. It goes without saying 
that no examination of the abdomen is permissible at the time of the 
hemorrhage. 

Prognosis and Treatment. — The prognosis and treatment is involved 
in the basic lesion (v. Typhoid). Symptomatic treatment includes 
absolute rest of body and mind; 5 grains of ergotin and one grain of 
opium should be given every two hours until bleeding ceases. 



(M). PILES. 

Etiology. — Hemorrhoids result from (a) stasis; portal stasis operates 
through the superior hemorrhoidal and inferior mesenteric veins, and 
is more potent than cardiac stasis, which congests the middle hemor- 
rhoidal and internal iliac veins; (6) from constipation, pregnancy, and 
other obstructive lesions, as cancer of the rectum. According to Duret, 
vigorous contraction of the abdominal muscles is more potent as a 
cause than is constipation. Piles are most common in the fifth decade 
of life and in men. Hemorrhoids are usually spoken of as varices but, 
as Reinbach has shown, they are often cavernous angiomata. 

Symptoms. — External piles appear as tender, painful, dusky-red or 
purple swellings outside the sphincter ani; they occur singly or may 
grow in a circle around the anus; they may be soft or hard. The pain 
produced is throbbing and may be very severe. Itching is very com- 
mon. They may bleed, waste, ulcerate, or suppurate. Piles which 
bleed are called "open," and those which do not are called " blind." 
Internal piles occur above the sphincter, below which they may prolapse 
and strangulate. Tenesmus, mucus secretion, and dull pain some- 
times referred to the back and the sacro-ileac articulation, may be noted. 

Diagnosis. — Mere inspection is sufficient to exclude prolapse, 
condylomata, papillomata, etc. The possibility of carcinoma in their 
etiology should be borne in mind. 

Treatment. — (a) General treatment should deal with the basic 
factors. Exercise is indicated for those of sedentary habits, and con- 
stipation (q.v.) should be relieved, (b) Local treatment: a small 
injection of cold water before each movement softens the irritating 
hard passage and constricts the piles, thereby favoring their reduction. 
Cleanliness is of prime importance in the relief of itching, for which 
also a 1 per cent, carbolic salve is of great value. In acutely painful 
cases a cocaine salve is beneficial. The following formulae are astrin- 
gent and anodyne : 



684 DISEASES OF THE DIGESTIVE TRACT 

Extracti opn gr. ij. 

Extracti belladonnse gr. ij . 

Acidi tannici oss. 

Olei theobromatis q.s. 

M. et ft. in suppositoria No. X. 
S. — One at bedtime. 

Or- 

Cocainae (alkaloid) gr.iij. 

Iodoformi gr. x. 

Orthoformi gr. v. 

Olei theobromatis q.s. 

M. et ft. in suppositoria No. XII. 
S. — One at bedtime. 

They must be given with reserve, lest the opium or cocaine habit be 
acquired. Surgical treatment is indicated when local measures fail. 



(N). DIARRHCEA. 

Definition. — Increased frequency of the stools with decreased con- 
sistence. Diarrhoea is not synonymous with intestinal catarrh, though 
a sharp differentiation is often difficult. In some individuals two or 
three movements a day are physiological. 

Etiology. — (a) Irritation from the intestinal contents may cause it. 
Diarrhoea cathartica; some cathartics, as the aromatics, increase 
peristalsis, and others, as salts, cause increased transudation; diar- 
rhoea dyspeptica is caused by intestinal or gastric dyspepsia, and by 
fruits and vegetables ; diarrhoea stercoralis is caused by irritation from 
the f secal masses ; diarrhoea entozoica is caused by intestinal parasites. 
In general there are two mechanisms : (i) the stools are hurried through 
the bowel by increased peristalsis (irritation of the ganglia in the gut), 
in which case bile is found in them; and (ii) there is increased serum 
transudation into the intestine, when little or no bile is found, (b) 
Nervous diarrh&a causes from two to fifteen thin movements, contain- 
ing no increased mucus ; they are attended by rumbling in the bowels, 
peristaltic unrest, and are chiefly observed after mental excitement, 
as in taking examinations, or in neurotic individuals (hysteria, neuras- 
thenia, or exophthalmic goitre) ; some cases are reflex, as from uterine 
or dental irritation, (c) Toxic substances in the blood may cause 
irritation of the ganglia or act upon the brain; for instance, uraemia, 
typhoid, sepsis, cholera, and possibly cold, produce diarrhoea by one or 
both of these mechanisms. 

Treatment. — Opium is the most valuable remedy in diarrhoea, 
except in the stercoral and dyspeptic types; it acts less by checking 
secretion than by suspending peristalsis and mitigating pain and 
spasm; the crude drug is superior to its alkaloids, as its absorption 
from the bowel is slower, and its effect is therefore more marked; | of 
a grain of the extract, or a dram of the camphorated tincture, should 
be given with bismuth in massive doses as in acute or chronic enteritis 



CONSTIPATION 685 

(q.v.). Important adjuncts are local heat (quieting irritation and peri- 
stalsis), rest, and a spare diet (boiled milk, eggs, toast, and later lean 
meat, as in enteritis.). In nervous diarrhoea two drops of Fowler's 
solution before meals is often advantageous. 



(0). CONSTIPATION. 

Constipation is a relative term, for some persons normally have 
movements every second or third day, and constipation (insufficient 
amount of faeces) may exist even with daily movements. 

Etiology. — (1) "Physiological" constipation results from irregu- 
larity in going to stool, as in travel, from obesity, from insufficient 
exercise or water, from loss of fluid by sweating, from a dietary rich in 
proteids, as milk, and from various kinds of over-medication. (2) 
Constipation may be symptomatic of other affections, as (a) gastric 
ulcer, cancer, dilatation, or hyperacidity; (b) intestinal obstruction, 
cancer, adhesions, catarrh, passive congestion, or Glenard's enter- 
optosis; (c) pelvic conditions, as pregnancy, ovarian or uterine 
disease, or enlarged prostate; (d) infections (which stimulate the in- 
hibitory nerves); (e) nervous disease, meningitis, tumors, myelitis, 
the neuroses; (/) diabetes and old age. (3) Habitual constipation, 
constipation per se, may occur in families. It may result from insuf- 
ficient nervous energy (acquired or congenital) in the large intestine. 
Atony of the intestinal muscle may result from general debility or 
marasmus; it is very frequently a sign of neurasthenia, hysteria, or 
hypochondriasis, and results but seldom from actual disease of the 
musculature itself — that is, from atrophy or degeneration. Nervous 
constipation may be due to a spastic condition of the bowels. 

Symptoms. — Symptoms other than constipation are often entirely 
absent, even after weeks, and when present are more often local (anor- 
exia, coated tongue, bad taste in the mouth, or abdominal uneasiness) 
than general. 

It should be remembered that two or three movements in one day 
or a movement every two or three days come within physiological 
limits. The stools normally accumulate in the sigmoid and pass every 
twenty-four hours into the lower rectum, causing a desire to defecate, 
usually at the same hour each day. The constipated stool is dry and 
accumulates in thehaustra of the colon or ampullae of the rectum. Con- 
stipation may occur even with daily movements, a small amount being 
retained each time. It is difficult to state the quantity of the normal 
passage, which certainly does not depend wholly on the amount of 
food ingested ; faeces consist largely of mucus and bacteria, and form 
even during starvation; experimentally, faeces form in a' loop of intes- 
tine isolated by ligature. The stools may resemble sheep's dung, and 
this is probably due to intestinal muscular spasm. Retained faeces are 
usually voided spontaneously in a few days as scybala covered with 
mucus which results from irritation or with a serous diarrhoea. Con- 



686 DISEASES OF THE DIGESTIVE TRACT 

siderable obstruction may cause fcecal colic, which is due to contraction 
of the gut above the obstruction; there may be stercoral fever and 
meteorism. The retained faeces may be palpable. Still more marked 
obstruction may very rarely simulate organic enterostenosis, being 
marked by collapse, vomiting, and great vesical or rectal tenesmus, 
which should always excite suspicion. Extreme neglected cases may 
occasionally result fatally, especially in the old, debilitated, or insane, or 
in cases in which defecation causes great pain, as from fistula or piles. 

Facal concrements (coproliths) almost always occur in the large 
intestine. When large they may simulate tumors of the intestine, 
omentum, kidney, or spleen, from which differentiation may be possible 
only after thorough purging and flushing. They may be soft and easily 
indented with the finger, hard, nodular, and tender from the bowel 
ulceration they incite, or, far less often, tender from localized peritonitis. 
The history is not always conclusive, because faecal tumors may develop 
with daily though inadequate movements. Gersuny found that on 
pressure the bowel may at first seem to adhere to the faecal masses and 
then become free, though the author and many others have failed to 
note Gersuny 's sign. 

General symptoms are uncommon. Nervous symptoms are usually 
causal rather than sequential, as in the neurasthenic subject, who 
believes he would be well if his bowels would move, and who has most 
unpleasant sensations when they do. Vertigo, pressure in the head, 
and mild dyspnoea are, in the author's opinion, always neurotic and 
never coprostatic. Copropsychiatry is, according to Nothnagel, grossly 
exaggerated. Intoxication (ptomainsemia) is rare, but has been con- 
sidered causal of neuralgia, chlorosis, and numerous other merely con- 
comitant conditions. The aromatic sulphates of the urine may be 
increased, which is due to formation in the gut of indol, skatol, and 
pyrocatechin. 

Treatment. — Treatment of the causal factors (q.v.) is most im- 
portant, as of irregularity of habit, insufficient exercise, or neurasthenia. 

1. Diet. — (a) Coarse foods, as whole wheat, graham, rye, corn 
meal, and bran breads, probably act less mechanically than chemically 
by the production of lactic or oleic acid, (b) Fruits relax the bowels, 
because of the malic, tartaric and citric acids they contain, as plums, 
apples, peaches, pears, prunes, strawberries, and grapes; grapes 
sometimes and bananas and persimmons usually cause constipation. 
(c) Vegetables act by the acids and gases they form ; melons, sprouts, 
cabbage, cauliflower, cucumbers, turnips, carrots, spinach, tomatoes, 
asparagus, onions, cress, celery, and squash, should be given freely, but 
it should be borne in mind that excessive amounts may cause fatigue of 
the bowel and constipation, (d) Sweets, in so far as they do not cause 
indigestion, are laxative; if used with discretion, sugars, syrup, candy, 
sauces, molasses, jellies, jams, marmalades, and honey, are valuable 
laxatives, (e) Fats — Moderate amounts of butter and olive oil are 
helpful; vegetable are superior to animal fats, which tend to derange 
digestion. (/) Cold water, taken on rising and through the day, is 



CONSTIPATION 687 

valuable in exciting peristalsis. Charged waters operate similarly. 
Hard water (containing an excess of lime) constipates, which point 
should be remembered both in regard to drinking and cooking, (g) 
The following are to be avoided: red wines (containing tannic acid), 
excess of meat, eggs or carbohydrates (rice, buckwheat, macaroni, 
and others containing little water), tea, milk (sometimes laxative when 
not taken in sips but swallowed in larger quantities) and beef tea. 
The diet recommended affords material for bacterial action, which 
follows the idea advanced by Strassburger and Lohrisch, that constipa- 
tion is "due to impaired motility, resulting in turn from too complete 
utilization of the average diet by the intestinal bacteria. 

2. Punctuality at Stool. — The necessity of being punctual at stool 
was insisted upon by Trousseau. The best time for evacuation is 
immediately after breakfast, except in cases of piles or prolapse which 
may come down during the day after the morning stool; in these 
cases the bowels should be moved at bedtime. 

3. Posture at Stool. — Squatting is the natural posture; this may be 
approximated by leaning well forward or by placing the feet on a foot- 
stool; the thighs thus support and compress the abdomen, a matter of 
particular importance when it is relaxed. Working the thumb of the 
left hand downward over the abdomen from the navel to the left iliac 
fossa is also recommended. 

4. Massage. — Massage may give relief if continued for months. 
Its direction is not especially important, though the course of the colon 
should be followed. It should be given for a quarter of an hour, pref- 
erably before breakfast. Sahli's method was to roll over the abdomen 
a 7-pound cannon-ball covered with chamois. Massage should be 
gentle, especially in the aged. It is seldom beneficial in the obese. It 
is indicated in atonic but contra-indicated in spastic constipation. 

5. Mild Faradization. — This arouses short contractions in the colon 
and is given with a moist sponge. Strong applications are avoided. 
Faradization and galvanization are inferior to massage. 

6. Hydrotherapy. — The cold compress to the abdomen is a good 
adjunct. 

7. Exercise. — Exercise is indicated to develop and contract the 
abdominal muscles, as in tennis, or rowing, or by lifting the legs while 
lying on the back, or lifting the rigid body from the lying to the erect 
posture solely by the abdominal muscles. Walking, bicycle-riding, and 
horse-back riding, do not exercise these muscles equally well. In women 
with ovarian and uterine diseases, exercise only increases the constipa- 
tion, which is generally due to reflex spastic inhibition of peristalsis, 
as shown by the laxative effect of narcotics (Littlejohn and Brunton). 
It is claimed that constipation is spastic (not atonic) in 25 per cent, of 
female cases, as evidenced by colic, palpable or visible knots in the 
intestine, and sometimes by ribbon-like passages; in these cases 
irritating and coarse diet, massage, cold, and electricity, are to be 
avoided. Hot Sitz baths or full hot baths, hot compresses to the 
abdomen for spasm or colic, are indicated; an enema of eight ounces of 



688 DISEASES OF THE DIGESTIVE TRACT 

warm olive oil is given each evening, and an attempt is made to have it 
retained until morning; one-third of a grain of extract of belladonna is 
given as a suppository one to three times a day, to relieve spasm and 
the frequent rectal tenesmus; the diet should not consist of coarse food 
but of fine carbohydrates, butter, and cooked fruit. 

8. Enemata. — Enemata excite peristalsis, lessen intestinal hyper- 
emia, and apparently are beneficial to the hepatic secretion and circu- 
lation. They do not derange digestion as do cathartics, but after a 
time they may lose their effect by dilating the colon, whence the 
indication for their intermittent use. Water and olive or linseed oil 
maybe used; oil enemata (five to eight ounces) are especially indicated 
in spastic constipation and colica mucosa, in which the oil may be 
left in the bowel over night. Glycerine suppositories are valuable, if 
used alternately with other methods. In fsecal impaction with marked 
obstruction enemata are invaluable, and should be combined with 
cathartics and digital evacuation of the hardened masses. 

9. Cathartics. — The use of cathartics is governed by the following 
general rules : (a) they should be administered in chronic cases only 
after failure of the measures enumerated above; (b) their most suc- 
cessful employment is intermittent and alternating; (c) drastics, 
hydrogogues, and cathartics producing secondary constipation, should 
be avoided, save, of course, in extreme cases. 

Varieties. — Aloes, found in nearly all proprietary and officinal pills, 
should be avoided in piles and uterine hemorrhage, because it congests 
the pelvic vessels. Like other cathartics, it is usually given in combina- 
tion, e.g. — 

Extr. aloes aquosi . . . . gr. ss. Acting in fifteen to twenty hours, on 

the large bowel chiefly. 

Extr. rhei. ....... gr. ij.tov. Actively purgative in four to eight 

hours; stomachic and tonic. 

Extr. nucis vomicae . . . gr. \. Acting on peristalsis and combating 

atony. 

Resinae podophylli . . . . gr. ^ Acting in ten hours, producing "bilious 

stools." 

Extr. belladonnas gr. i- Relieving spasm (griping) and operating 

(or extr. hyoscyami) on the intestinal nerves. 

Extr. teraxici gr. j . 

M. et ft. pil. I. 

Rhubarb has the disadvantage of griping and of producing secondary 
constipation, which is caused by its tannic acid ("a patient sells his soul 
to rhubarb"), whence it should never be given alone: 

Pulveris rhei compositi . . . . oiv. 

Sodii sulphatis 5iv. 

Sodii bicarbonatis oj- 

M. et S. — One teaspoonful at bedtime. 



FUNCTIONAL (NERVOUS) AFFECTIONS OF THE BOWEL 689 

Cascara sagrada is an excellent laxative, and produces very little 
constipation afterward; the fluidextract, fluidextractum rhamni 
purshianse, tt^x to xx, is very bitter; the solid extract, extractum 
rhamni purshianse, is given in doses of from two to eight grains. 
Licorice is given as pulvis glycyrrhizse composite, 3ss to 5j- Castor 
oil is a soothing laxative, relieving irritation and spasm (in nervous or 
lead constipation, in which latter it may be combined with opium gr. 
|); its offensive taste may be partly overcome by combining with 
glycerine and gaultheria: 

Olei ricini 5 ij • 

Olei gaultherise gtt. xl. 

Glycerini Sij. 

M. et S. — One teaspoonful to one tablespoonful. 

In ansemic patients the following formula is recommended: 

3 



Ferri sulphatis . . . . ■ . 

Extracti aloes aquosi . . . 
Extracti rhamni purshianse 

Extracti belladonnse . . . 

Extracti nucis vomica? . . 
M. et ft. pilulaB No. X. 
S. — One after meals. 



gr. x. 

gr. v. 
gr. xx. 
gr. iij. 
gr. iij.. 



Calomel should be given in the evening in fractional doses, and mayjbe 
advantageously combined with podophyllin, which acts in the same 
time (eight hours) ; they should be followed the next morning by half 
an ounce of magnesium sulphate. Senna easily deranges digestion ; a 
small amount may be added to prunes and both cooked together; 
confectio senna is given in dram doses. Tobacco smoking, and 
coffee in the morning, are beneficial, but tea promotes flatulency 
and constipation. Consideration of the salines and drastics is inten- 
tionally omitted, as their use except for emergencies is contra-indicated. 



(P). FUNCTIONAL (NERVOUS) AFFECTIONS OF THE BOWEL. 

1. Neuroses of Motility. — (a) Nervous diarrhoea has been partly 
considered. It may occur in the neuroses, in reflex irritation during 
dentition, or in the crises of tabes; it is usually transient and is marked 
by absence of inflammatory symptoms, as mucus, pus, or blood. There 
is constant danger that nervous diarrhoea may be confused with organic 
disease. In some cases ingestion of food may be immediately followed 
by diarrhoea, and is treated by giving ir^ij of Fowler's solution before 
meals, (b) Enterospasm is caused by simultaneous contraction of the 
circular and longitudinal muscles, which normally contract alternately ; 
the abdomen is temporarily retracted, and in very exceptional cases 
obstruction (ileus spasticus) and fsecal vomiting occur. (See Dynamic 
Ileus, Spastic Constipation and Colica Mucosa.) (c) Sphincter 
spasm, aside from local rectal or anal lesions, results from sensory 

44 



690 DISEASES OF THE DIGESTIVE TRACT 

hyperirritability, or decreased cerebral inhibition ; it is most common 
in hysteria and tabes, (d) Peristaltic unrest may be associated with 
diarrhoea if the colon is involved, but more commonly affects the small 
bowel only, when constipation or normally frequent movements are 
usual. {e) Nervous constipation (atony) may result from the 
neuroses, intoxication from carbon dioxide, and organic cerebrospinal 
diseases, in which condition (/) sphincter paralysis may also result. 

2. Neuroses of Sensation. — Among the neuroses of sensation, neu- 
ralgia mesenterica (enteralgia, enterodynia) is most important; it is 
inflammatory, nervous, or colicky in origin; strictly speaking, it is 
always nervous, i. e., not due to organic causes; practically, other forms 
of abdominal pain are frequently included under enteralgia. The chief 
symptom is the abdominal pain, which is usually umbilical, and some- 
times relieved by pressure and sometimes is not; the abdominal wall 
itself may be hypersesthetic. Reflex disturbances in other organs may 
accompany enterodynia and aid in establishing its functional character; 
they are hiccough, vomiting, dyspnoea, palpitation, rectal or vesical 
tenesmus, testicular retraction, muscular twitchings, etc. The diag- 
nosis necessitates exclusion of innumerable affections, chiefly abdom- 
inal but also general: (a) rheumatism of the abdominal muscles 
which is superficial; (b) lumbo-abdominal neuralgia, in which 
Valleix's three tender points are found (see Neuralgia); (c) hys- 
teria, which may simulate many affections; its stigmata should be 
looked for; (d) tabetic crises; (e) intestinal affections, as appendicitis, 
peritonitis, coprostasis, parasites, flatulent colic (from beer, milk, or 
spoiled food), excessive catharsis, lead colic, or colica mucosa; (/) 
gout, arthritis, or cold; (g) malaria and typhoid; (h) renal and biliary 
calculi. 

Its treatment and that of the motor disturbances is of the fundamental 
nervous state. Symptomatically, hypodermics of narcotics produce the 
quickest but most dangerous cure. 

A hypodermic injection of atropine is often helpful. 

3 .... . . 

Spiritus ammonii aromatici oiij. 

Tincturse cardamomi compositge oiij. 

Spiritus chloroformi oij. 

Tincturse opii camphoratse oiv. 

Tincturse asafcetidse 5iv. 

M. et S. — One tablespoonful in hot water every fifteen minutes for three or four 
doses. 

3. Neuroses of Secretion. — The secretion neuroses are important. 
The chief types are serous nervous diarrhoea and colica mucosa, which 
have already been considered. 



(Q). AFFECTIONS OF THE MESENTERY. 

I. Inflammation. — Mesenteritis is chiefly important in its relation 
to ascites, tuberculous peritonitis, and other peritonitides (q.v.). 



AFFECTIONS OF THE MESENTERY 691 

II. Hemorrhage. — Hemorrhage is most rare as a primary manifes- 
tation. It is generally secondary to acute hemorrhagic pancreatitis, 
retroperitoneal hsematoma, aneurysmal extravasation, or the hemor- 
rhagic specific fevers. 

III. Diseases of the Mesenteric Vessels. — (a) Infarction by 
embolism or thrombosis was first described by Virchow, and involves 
chiefly the arteria mesenterica superior, which is essentially a terminal 
vessel. Most cases develop in men past middle life. Jackson, Porter, 
and Quimby, have collected 225 cases. (See Symptoms of Valvular 
Heart Disease.) Its onset is sudden, with intense abdominal pain, 
collapse, nausea and vomiting (usually bloody and perhaps fecal, due to 
intestinal obstruction), diarrhoea (40 percent.), and bloody stools (40 
per cent.). Unless there is an apparent cause for embolism, as (mitral) 
valvular disease, the diagnosis of infarction is rarely made, for periton- 
itis or obstruction is usually suspected. The usual outcome is early 
death from collapse, but sometimes, if the patient lives long enough, 
acute peritonitis sets in, with distended abdomen and diffuse tender- 
ness. In very rare cases collateral circulation allows of recovery. In 
the Porter, Jackson, and Quimby series, 94 per cent, were fatal. The 
treatment is purely symptomatic and supportive, but successful opera- 
tion is recorded by J. W. Elliott, Leclerc, and Buetter. (b) Peri-arteritis 
nodosa (v. Diseases of the Vessels), (c) Dilatation of the mesenteric 
veins and phlebosclerosis occur, especially in cases of liver cirrhosis. 
(d) Suppuration (thrombophlebitis suppurativa) may mark umbilical 
pysemia of the new-born or may carry infection from the appendix 
or rectum. (See H^ematemesis.) (e) Simple thrombosis of mesenteric 
veins. Kraft in 1897 collected 16 cases; in over half of the cases syphilis 
or liver cirrhosis was the cause. 

IV. Affections of the Chyle Vessels. — These offer more patho- 
logical than clinical interest. These vessels may become varicose or 
even hyperplastic (chylangioma). Cysts containing chyle may cause 
tumors, and, by rupture, may result in chylous extravasation in the 
mesentery, or chylous ascites (q.v.). Twenty-four chylous cysts are 
described by Broca. 

V. Mesenteric Tumors. — These ma\ be dermoid, hydatid, serous, 
sanguineous, chylous, or malignant. In some cases they may attract 
only accidental pathological attention, or they may in other instances 
fill the entire abdomen. Their symptoms are those of an abdominal 
tumor, which is centrally located, is movable, and covered with a zone 
of resonant intestine. Confusion is possible with hydronephrosis or 
ovarian cvsts. 



692 DISEASES OF THE LIVER 

DISEASES OF THE LITER. 

(A). ACUTE YELLOW ATROPHY. 

Definition. — An acute and usually fatal degeneration of the liver 
cells, accompanied by shrinking of the liver, icterus,, and nervous 
toxaemia. Ballonius (1600) reported the first case. It is a rare affection; 
Best collected 450 cases. 

Etiology. — (a) Sixty-six per cent, occurs in women and 50 per cent, 
between the ages of twenty and thirty years. It is rarely observed in 
infancy or old age. (b) Thirty-three to 50 per cent of women with the 
disease (or 27 per cent, of all reported cases) are in the last half of preg- 
nancy; the first three months of gestation almost render the individual 
immune (Eichhorst). It occurs less frequently in the puerperium. 
(c) It rarely occurs as an epidemic; 10 soldiers were affected in Ar- 
nould's series, (d) Infections, as osteomyelitis, diphtheria, sepsis, 
erysipelas, typhoid, recurrent fever, and secondary syphilis (10 per cent. 
Lebert); or (e) poisoning, as from phosphorus, alcohol, ptomaine 
poisoning, chloroform narcosis, and possibly bacterial poisons, may 
antedate the disease. 

It may occur primarily in a sound or secondarily in a diseased liver 
(fatty or cirrhotic liver, or in bile stasis). Worry is thought to be a 
predisposing factor, caused, e. g., by pregnancy or syphilis. 

Pathology. — The liver is small, the minimum weight recorded being 
400 grams, or about thirteen ounces ; in marked cases it is so lax that it 
can be rolled up; the capsule is wrinkled ; the color is usually yellow 
(atrophia hepatis fusca), and the lobular markings are obscure. The 
liver cells are granular, fatty, indistinct in contour, and some are tinged 
with bile; some are necrotic and others show evidences of regeneration. 
Foci of red tissue are observed; this is usually considered as an ad- 
vanced stage in which the fatty necrotic cells have been absorbed; 
this tissue shows few or no cells, is homogeneous, and is composed of 
detritus; the left lobe is often red, showing the most advanced process, 
and the right lobe is yellow, shoving the earliest changes. The cells of 
the bile channels are degenerated and sometimes appear to multiply. 
Crystals of tyrosin are found. The apparent increase of the connective 
tissue is relative only. Sometimes infiltration with red or white cells 
occurs. In other organs icterus staining, small hemorrhages, and fatty 
degeneration, are found, as in the heart, kidneys, muscles, epithelial 
cells, and glands of the bronchi, lungs, and digestive tract. 

In nature the disease is sometimes considered inflammatory (acute 
parenchymatous hepatitis), but is usually classified as a degenerative 
or necrotic process. It is not yet determined whether the disease is an 
infection, to which it has a certain resemblance., or an intoxication. The 
changes in other organs are held to result from the liver change or from 
a common unknown cause. Bacteria are found in some cases, but their 



ACUTE YELLOW ATROPHY 693 

role has not yet been determined. Various microorganisms have been 
found at autopsy, as the pneumococcus, pyogenic organisms, colon 
bacillus, and other organisms, but not in all cases ; Prochaska cultivated 
the streptococcus, from a case of Eichhorst, before death. 

General Clinical Picture. — Acute yellow atrophy begins with a 
prodromal stage in which stomach disturbance predominates; icterus 
develops in a few days or a week, and the second stage then begins 
suddenly with cerebral symptoms of unrest, delirium, oppression, vom- 
iting and convulsions; with shrinking of the liver, hepatic tenderness, 
enlarged spleen, cutaneous and mucous membrane hemorrhages, 
abortion and hemorrhage if pregnancy exist; with urinary symptoms, 
as bile, albumin, leucin, tyrosin, and other unusual products of metab- 
olism in the urine; and with subnormal or normal temperature. The 
issue is almost invariably fatal. 

Individual Symptoms. — The prodromal stage may last from a few days 
to three and a half weeks or more, and is not characteristic. In the latter 
half of gestation, icterus and hepatic tenderness are suspicious symp- 
toms. The stomach symptoms and icterus become marked. Icterus, 
which is rarely absent except in extremely rapid eases, is obstructive 
from intrahepatic changes; the stools are light (acholic) and the 
jaundice increases with the second stage. Occasionally there is some 
prodromal swelling of the liver. 

In the second stage, (a) the hepatic dulness lessens to one-half or 
one-quarter of its former dimensions, which first involves the left lobe. 
The liver is small, flabby, and falls back toward the spine so that in 
some cases there is no liver dulness. The liver dulness may remain 
normal, first, if death is rapid, as from hsematemesis (Leube) ; second, 
if the liver is cirrhotic; or, third, if it is adherent to the abdominal wall. 
The liver is tender and painful, and pain is occasionally referred to 
other parts of the abdomen. The region of the liver may appear 
sunken and the liver may feel flabby or may pit to the finger (Leube). 
(b) The spleen is enlarged in 66 per cent.; it is not enlarged when 
perisplenitis, profuse hemorrhage, or diarrhoea, are present, (c) Vomit- 
ing is almost invariable, the vomitus consisting of mucus, bile, and 
finally blood; it is accompanied by hiccough, a dry brown or white 
tongue, sordes, and constipated, usually uncolored, stools, (d) The 
nervous symptoms may come on gradually with headache and dulness, 
or very abruptly with delirium, anxiety, meningeal symptoms, grinding 
of the teeth, trismus, wide pupils, amaurosis, cerebral vomiting, and 
convulsions (in 33 per cent, of adults and almost constantly in chil- 
dren). The nervous symptoms are due to hepatic insufficiency (hepa- 
targia), the degenerated liver being unable to protect the nervous 
system, as it does in health, against various ptomaines and leuko- 
maines. (e) The urine is decreased or even suppressed. Bile pigment, 
albumin, casts, and epithelial cells, are found. Unusual products are 
found in the urine, due to the breaking down (autolysis) of the liver 
cells; leucin and tyrosin occur most frequently, though they are neither 
constant nor pathognomonic; sarcolactic acid, oxyamygdalic acid, 



694 DISEASES OF THE LIVER 

peptone, and albumose, are also found. The urea is decreased and 
may be entirely absent. The ammonium compounds, which normally 
constitute 2 to 5 per cent, of the nitrogen excretion, are increased, 
even to 17 or 20 per cent., because they are needed to neutralize the 
increased amount of acid products in the blood and because the liver 
cells cannot convert the ammonium compounds into urea. The uric 
acid and xanthin are increased. Indicanuria may be noted. Strangely, 
glycosuria is rare, though the glycogenic function of the liver can 
hardly be normal. Bouchard, Hervouet, Brouardel, and Chauffard, 
speak of urinary crises with increase in the amount of urine voided 
and in its nitrogenous constituents. (/) Fever may occur earlv in the 
disease, but the temperature is usually normal or subnormal at the 
height of the process. The pulse may be at first slow, but later becomes 
very rapid. Dyspnoea is almost invariably present, (g) Hemorrhages 
occur in the majority of cases, largely from the stomach and into the 
skin. Bowel hemorrhage is less frequent, as are those from the nose, 
mouth, and genital mucosa?. Uterine hemorrhages occur if pregnancy 
exist. Hemorrhages in the retina are frequent, together with white 
flecks due to tyrosin deposit and fatty change. Punctate hemorrhages 
into the serous membranes are common autopsy findings. Erythem- 
atous eruptions, muscular pain, and articular swellings, may occur- 
In a case seen by the writer herpes was the first symptom. Leuko- 
cytosis is infrequent. 

Course. — The clinical course is rapid; 50 per cent, of cases die 
between the fifth and fourteenth days, and 30 per cent, between the 
third and fifth week. The second stage usually lasts one and a half 
to three days, rarely more than a week, but may be longer in the rare 
cases which recover. The more abrupt and severe the cerebral 
symptoms, the more rapid is the course. Pregnancy hastens the issue. 
Remissions may be observed; temperature may develop during the 
death agony. The pulse becomes very rapid, the breathing difficult 
and irregular, and the symptoms of nervous excitation are followed 
by paralysis of the brain centres. 

Diagnosis. — The diagnosis is based upon (a) the icterus, (b) nervous 
symptoms, and (c) shrinking of the liver. Diminution of the liver may 
be simulated by tympanites or by the colon lying over the liver; it 
may not shrink when previously cirrhotic or when bound to the abdom- 
inal wall by adhesions, even though the liver cells atrophy. The urine 
shows distinct disturbances of metabolism, which are valuable diag- 
nostically with the above mentioned symptoms. Confusion may occur 
in icterus gravis, or in the so-called bilious typhoid, pneumonia, recur- 
rent fever, puerperal fever, yellow fever, phosphorous poisoning or 
Weil's disease; most of these affections are febrile, while acute yellow 
atrophy is almost always without fever; in addition to this, the intensity 
of the icterus and shrinking of the liver, severe cerebral symptoms in 
which periods of depression and exaltation alternate, and the urinary 
findings, are diagnostic. The greatest difficulty of diagnosis is in 
acute phosphorous poisoning, for which Quincke gives the following 



PORTAL CIRRHOSIS 



695 



differentiation, though Leube maintains that differentiation is impos- 
sible, except etiologically. 



Acute Yellow Atrophy 

One to two weeks of moderate symp- 
toms from icterus. 

Icterus intense. 

Liver sensitive, smaller. If colon is dis- 
tended, entirely obliterating the liver 
dulness, the urinary symptoms are 
suggestive. 

Liver cells greatly degenerated, and but 
little increase in the fat (5 per cent.). 

Sudden cerebral symptoms with alter- 
nating irritation and depression one 
to two days before death. 

Urine; oxyamygdalic acid, leucin, 
tyrosin. 

Hemorrhages: smaller and fewer. 
Duration of one to two weeks. 



— vs. — Acute Phosphorous Poisoning. 

Acute gastro-intestinal symptoms; then 
icterus on the third day. 

Icterus less. 

Liver sensitive and swollen. 



Very extensive fatty degeneration (30 
per cent.). 

Cerebral symptoms more of depressive 
order. 



Sarcolactic acid (though peptone, sarco- 
lactic and tyrosin are found in both 
diseases). 

Hemorrhages: more numerous. 

Duration shorter. 



Though admitting that subjects of acute yellow atrophy may recover, 
such recoveries usually indicate errors in diagnosis. From simple 
atrophy of the liver differentiation is easily made by the general mar- 
asmus and the absence of icterus and of nervous and urinary symp- 
toms. Cirrhosis is differentiated by absence of ascites and the presence 
of a larger spleen, firmer liver, and collateral circulation (v. page 724). 

Treatment. — Treatment is wholly expectant and entirely negative 
in its results. The heart depression, vomiting, and nervous excitement, 
are treated as in typhoid (q.v.). 



(B). PORTAL CIRRHOSIS. 



Synonyms. — Laennec's cirrhosis, alcoholic or atrophic cirrhosis. 

Classification. — The classification of the varieties of cirrhosis is 
difficult; it may be made upon an etiological, pathological, or clinical 
basis. From a practical standpoint the chief points are included in 
the following classification: 



(1). 



Capsular or 
Glissonian. 



(2). Vascular. 



(3). Biliary Cirrhosis. 
(4). Mixed Cirrhosis. 



Portal vein syphilis. 
Chronic perihepatitis. 

Portal vein cirrhosis, first in clinical importance; its 
leading type is the alcoholic, atrophic type of Laeimec, 
(A sub-type is a hypertrophic cirrhosis, like the 
atrophic in every respect save that the liver rema ins 
large.) 

Hepatic vein cirrhosis, occurring in stasis (cyanotic 
induration), and, according to French authors, with 
portal vein cirrhosis. 

Hanot's disease. 

(Portal vein and biliary cirrhoses combined.) 



696 DISEASES OF THE LIVER 

Of these forms, given in the hope of elucidating the numerous 
classifications, two main forms are conspicuous — the portal and biliary. 

Definition. — Portal cirrhosis is a fibrosis of the liver, characterized 
(a) etiologically by alcoholism; (b) anatomically, by induration around 
the portal vein radicles and enclosing numbers of liver lobules, whose 
cells degenerate; and (c) clinically, by portal obstruction (dyspepsia, 
hsematemesis, enlarged spleen, and ascites), and often by signs of hepatic 
insufficiency. 

Etiology. — (a) Sixty to 75 per cent, of cases are found in men 
between forty and fifty years of age. Musser (1889) collected 685 
cases in children, (b) Alcoholism is the chief though not the sole 
cause ; cirrhosis may be due to whisky, wine, beer, or absinthe, especially 
in sedentary individuals ; alcohol is absorbed by the gastric and intestinal 
veins, and is conveyed to the portal vein radicles, where its toxic 
effects are expended on the liver cells or interstitial tissue, but in what 
sequence it is not known. Of late the role of alcohol has been dis- 
puted, but it remains a striking though perhaps an indirect factor, 
(c) Syphilis is a cause, especially in the young, in whom the toxins 
are directly conveyed, by the umbilical vein, to the liver, (d) Other 
infections, as malaria (especially where it is endemic), cholera, typhoid, 
tuberculosis, scarlet fever, measles, and diphtheria, are possible causes; 
experimentally cirrhosis has been caused by the Bacillus pyocyaneus, 
Bacillus coli, and staphylococcus; focal mycotic necrosis is thought 
to be followed by fibrosis; in this group the toxins probably enter by 
the hepatic artery, (e) Spices, curry, drastics, lead, phosphorus, 
arsenic, hemochromatosis, anthracosis (Welch), silicosis (Adami), cer- 
tain shell-fish, and possibly auto-intoxication from dyspepsia, are excep- 
tional etiological factors. It may be associated with gout, diabetes, 
rickets, or other constitutional affections. Experimental cirrhosis has 
been produced by lactic, acetic, and butyric acid. There may be 
multiple causes, e.g., syphilis plus malaria or alcoholism. In some 
cases no cause is discoverable. 

Pathology. — The essential change is fibrosis around the branches 
of the portal vein. Some consider that the connective tissue growth is 
primary, causing, as it contracts, atrophic or fatty alteration of the 
liver cells, sometimes with pigmentation; others maintain that the 
cells are first injured and are replaced by fibrous tissue. Whatever 
the pathogenesis, the connective tissue forms and surrounds several 
lobules at a time (multilobular cirrhosis). Histologically the cirrhosis 
is atrophic, and this point is emphasized first, because the size and 
weight of the liver may vary. Some clinicians maintain that the liver 
is first large (the so-called hypertrophic stage) and later is shrunken. 
Undue importance is attributed to size alone, for a normal-sized or 
even enlarged cirrhotic liver is histologically atrophic. An actually 
atrophic liver may be large from (a) fat deposit, (b) passive congestion, 
(c) compensatory hyperplasia, or (d) active congestion. The weight 
is usually decreased from 1,500 or 2,000 gm. (50 or 65 ounces) to 1,000 
gm. or less. Its edge is rough; i.e., granulations can be felt which 



PORTAL CIRRHOSIS 697 

represent the remaining relatively normal liver tissue. The surface 
is sometimes smooth, and microscopic examination may be necessary 
for confirmation. Granulations also occur in fatty liver, pylephlebitis, 
and passive congestion. Its consistence is increased. The liver is 
gritty to the knife; its color is yellow (cirrhosis), perhaps green or 
brown. The connective tissue is increased and prominent, encroaching 
on the parenchyma. Injections of the organ through the portal vein 
are not successful; i.e., there is portal obstruction, which causes many 
of the clinical symptoms. No connection between the portal vein and 
the hepatic artery can be demonstrated, though injections are success- 
ful through the hepatic artery and the biliary system. 

General Clinical Picture. — The disease often exists for several years 
without symptoms; this latency is usually marked by enlargement of 
the liver, which is due to compensatory hyperplasia. In the minority 
of cases, swelling, pain, or active hyperemia of the liver, dyspepsia, 
fever, or icterus, are observed; they last a short time only and are by 
no means characteristic. With marked shrinking there are symptoms 
(a) of general disturbance of nutrition, as constipation, emaciation 
(which is often not noticed because the abdomen remains obese), and 
an earthy, sallow look to the skin, in which dilatation of the small 
arterioles (toxaemia or alcoholism), dryness, and hemorrhages, are also 
observed; (6) of portal congestion, as early hsematemesis, epigastric 
pressure, ascites, small liver, large spleen, and disturbed breathing, 
circulation, and digestion ; (c) of intoxication, resulting from functional 
failure of the heart, liver, and kidneys, (d) There may be complica- 
tions, as hemorrhage, diarrhoea or the so-called cholpemia. 

Symptoms. — 1. The Liver. — The liver may be enlarged at first; it 
is enlarged about as often as it is decreased in size; the left lobe suffers 
most and earliest contraction. The liver may be found to be high, as 
a result of paresis of the diaphragm, due to perihepatitis. Its edge is 
hard, but often cannot be felt, even after tapping, on account of its 
shrinkage or because the bowels cover it. The edge is uneven, but its 
granulations may be confused with the small islets of the fatty tissue 
in the abdominal wall, which are due to unequal disappearance of 
the adipose tissue as a result of emaciation. Palpation of the liver 
is the only certain way of determining its lower limit, the results of 
percussion being decidedly unreliable. In infantile forms of portal 
cirrhosis the liver and spleen are larger than in adult types. 

2. Portal Stasis. — This results from obstruction to the return portal 
circulation, (a) The peritoneum is thickened, cedematous, and the 
seat of transudation, i.e., ascites, which occurs in 85 per cent, when 
the patient dies of the cirrhosis itself and in 50 per cent, when he dies 
from other causes. It is more common in small than in large livers. 
Some writers hold that toxaemia and peritonitis are more potent factors 
than portal obstruction. Ascites usually appears first without general 
oedema, though later the legs may become swollen as the ascites com- 
presses the inferior vena cava. Pre-ascitic oedema of the legs or abdom- 
inal wall may develop from cardiac or renal complications, involvement 



698 DISEASES OF THE LIVER 

of the cava by perihepatitis, or from thrombosis of the iliac veins. 
Under ascites, its physical signs will be more closely considered. 
The amount of fluid may be enormous; Liebermeister reports a case 
in which he withdrew nine gallons. 

The fluid is usually amber-colored, seldom red from admixture of 
blood, or very rarely turbid from fat (adipose ascites) or lecithin 
(chyliform ascites) ; the two latter forms also contain nucleo-albumin. 
The specific gravity is 1,008 to 1,015, with 0.6 to 1 per cent, albumim 
Though ascites is rather rarely absent in advanced cases of atrophic 
cirrhosis, the patient may die before ascites develops — for instance, 
from hemorrhage, which is dangerous when there is no ascites (Ley- 
den). An extensive though slowly developing collateral circulation 
may permanently relieve an earlier ascites. It is not an infallible 
sequence of atrophic cirrhosis (Lecorche, Hanot), and may disappear 
after hemorrhage (Fauvel), diarrhoea (Linas), or carcinoma of oesoph- 
agus (Lecorche, Telamon). (b) The spleen is from two to six times 
its normal size, which is due to the early toxaemia and the later stasis. 
The splenic tumor is present in 75 per cent, of cases and is a measure 
of the degree of cirrhosis. Its capsule is hard and thickened (some- 
times preventing splenic enlargement), the trabecular are thicker, and 
a systolic murmur is sometimes heard (Bouchard and Leudet). (c) 
Gastro-intestinal catarrh is due to stasis and to alcoholism. Pain after 
eating, especially in obese persons, a coated tongue, vomiting, singultus, 
constipation, piles, diarrhoea (which is rare unless toward the end 
of the course), and meteorism, also occur, (d) A collateral circulation 
may be evidenced by enlargement of the veins about the navel {cir- 
somphalos or caput Medusa). Prominence of the epigastric veins 
occurs regularly, but results from compression of the inferior cava. 
Anastomoses occur (i) between the median and inferior hemorrhoidal 
veins (passing by the hypogastric to the cava) on the one hand, and the 
superior hemorrhoidal (passing by the superior mesenteric to the portal 
vein) on the other hand; (ii) between the coronary veins of the stomach 
on the one hand, and the oesophageal and phrenic veins on the other, 
which empty into the vena azygos; (hi) between the veins in the liga- 
ments of the liver and new adhesions and the phrenic veins; between 
the veins of the ligamentum teres and the veins of the abdominal wall 
and epigastric veins, which may sometimes be felt and may produce 
murmurs (Bamberger and von Jaksch); (iv) the mesenteric, peri- 
toneal and parumbilical veins also communicate with those of the 
abdominal walls. A well-developed collateral circulation is both a 
favorable and an unfavorable symptom; on the one hand it relieves 
the portal stagnation and probably gives the over-taxed liver a better 
opportunity to perform its functions; on the other hand, the dilated 
collateral vessels are likely to rupture and they convey directly into the 
general circulation toxic substances which the liver normally destroys 
or alters; this produces, according to Stockton, the frequent arterio- 
sclerosis, granular kidneys, and more acute toxaemia, which resembles 
uraemia, (e) The kidneys are congested, degenerated, and often show 



PORTAL CIRRHOSIS 699 

hypertrophy. The urine is decreased in amount, darker, and of higher 
specific gravity, because the arterial tension is low in cirrhosis. More 
urine is often secreted during fasting than during digestion (opsiuria), 
which is the converse of normal conditions. The urobilin may be 
increased two-fold, giving a fluorescent filtrate when equal parts of 
urine and a 10 per cent, solution of zinc acetate in absolute alcohol are 
mixed and filtered. The chlorides are decreased, as they accumulate 
in considerable amounts in the ascitic transudate. The urea is often 
decreased, but the ammonium compounds (as in acute yellow atrophy) 
are often increased, less from interference with the liver functions 
than from increase of acid products in the blood (acidosis), which the 
ammonium salts seek to neutralize. Albuminuria may result from 
stasis or nephritis (v. i.). Blood may be found in the urine, as a result 
of stasis in the bladder. Glycosuria is uncommon save in the pig- 
mentary cirrhosis (see Diagnosis). Alimentary glycosuria may be 
produced by administration of 100 gm. (3 ounces) of grape sugar with 
a meal. 

3. General Symptoms. — There is considerable loss in weight, some 
anamia, and a sallow, earth-like color. Great malnutrition is readily 
explained (a) by the inability of the liver to properly handle the carbo- 
hydrates, proteids, etc., and (b) by the diversion through the collateral 
circulation of toxins into the general circulation, because the liver is 
the normal barrier against toxins which are injurious to the nervous 
system. In a recent case with well-developed collateral circulation, 
scurvy developed which the writer interpreted as toxsemic. It was 
once thought that bile salts or pigment entered the blood and produced 
"chol&mia," or that substances were retained which the bile normally 
excreted, producing " acholia"; now the term liver insufficiency (hepa- 
targia) is more often employed. Toxsemic nervous symptoms include 
adynamia, headache, itching, delirium, stupor, convulsions, paralysis, 
contractures, or coma. Much depends upon the activity and integrity 
of the kidneys, which may for a time maintain adequate excretion. 

Complications of Cirrhosis. — 1. Hemorrhage. — (a) Cachectic capil- 
lary hemorrhage from the nose, mouth, lungs, or stomach, is less fre- 
quent than it is in biliary cirrhosis. Epistaxis occurs from dilatation 
of the vessels on the anterior part of the septum. (6) Of mechanical 
congestive hemorrhages from the oesophagus, stomach, bowels, kid- 
neys, bladder, or uterus, those from the oesophagus are most important. 
Zenker found oesophageal varices in 20 per cent, of cirrhosis autopsies. 
Their rupture causes hamatemesis (which occurs in 23 per cent, of 
cirrhosis cases), chiefly in adults and rarely in children; if they are 
very profuse, blood may come up without vomiting. It is usually an 
early symptom, antedating ascites; the amount is generally profuse, 
and in one of Osier's cases amounted to 10 pounds; it often causes 
blood in the stools. It may pour out slowly and form dark clots; it 
is usually attended by less collapse than is hemorrhage from ulcer, 
but acute anaemia or slight fever may follow it. Preble in a careful 
study of the subject concludes that: (i) Hemorrhage is not a rare com- 



700 DISEASES OF THE LIVER 

plication of cirrhosis, (ii) It occurs chiefly in atrophic forms, (hi) 
In 33 per cent, the first hemorrhage is fatal; in 66 per cent, hemor- 
rhages occur over a period of several months to years, eleven years 
being the maximum, (iv) In 33 per cent, a diagnosis of cirrhosis was 
possible at the time of the first hemorrhage, (v) (Esophageal varices 
were present in 80 per cent., and in over half of these macroscopic 
rupture was detected; yet (vi) fatal hemorrhage may occur without 
macroscopic rupture, and is due to a simultaneous rupture of many 
capillaries, (vii) Hemorrhage may be the first sign of cirrhosis, but 
other symptoms are usuallv found first, (viii) The symptoms of 
cirrhosis were typical in but 6 per cent, of cases of oesophageal varix. 

2. Peritonitis. — (a) Chronic retracting peritonitis (in 10 to 19 per 
cent., Gratia), may occur with shortening of the mesentery and intes- 
tines; according to Botazzi it prevents absorption of the ascites, (b) 
Tuberculous peritonitis (10 to 25 per cent.) may occur with fever, pain, 
and often a hemorrhagic exudate which produces tuberculosis on 
inoculation. It usually follows the ascites of cirrhosis (the converse 
being very rare) and hastens the fatal outcome. One would think 
that stasis would tend to prevent the development of tuberculosis. 

3. Nephritis. — Nephritis occurs in 33 per cent, of cases. 

4. Heart. — The heart is arteriosclerotic in 60 per cent.; chronic 
myocarditis, endocarditis, fatty degeneration, and dilatation of the 
right ventricle, often occur. The arterial tension is low in cirrhosis. 

5. Lungs. — In the lungs, oedema, catarrh, emphysema, various in- 
flammations, and very frequently pulmonary tuberculosis occur; the 
latter is rare in infantile cirrhosis. Right hydrothorax occurs from 
stasis in the vena azygos and in the right intercostal veins; right- 
sided pleurisy, due to extension of perihepatitis through the diaphragm, 
occurs in 10 per cent, of cases (Caro). 

6. Brain. — Pachymeningitis, meningitis, or brain hemorrhage, may 
occasionally occur. 

7. Fever. — "Intermittent hepatic fever" may result from hepatargia 
(hepatic intoxication), perihepatitis, or from complications. The tem- 
perature is usually subnormal in advanced cases, though the author 
has often observed slight terminal temperature and leukocytosis, which 
is referable to terminal infections. 

8. Icterus. — In atrophic cirrhosis jaundice is a genuine complica- 
tion; it is due to duodenal catarrh, enlarged portal glands, or a diffuse 
cirrhotic process (Andral), though few patients pass through the dis- 
ease without having a muddy yellow areola under the eyes. If present 
it is incomplete, and is caused by compression of bile ducts by con- 
tracting connective tissue. Its frequency is 15 to 20 per cent. 

9. Anasarca. — Anasarca results from pressure on the cava by an 
extensive ascites, from perihepatitis with cicatricial involvement of the 
cava, and from complicating cardiac or renal disease and marasmus. 

10. Other Complications. — These are rarer; for instance, pyle- 
thrombosis, clubbed fingers, alcoholic multiple neuritis, or delirium 
tremens; acute yellow atrophy and venous thrombosis seldom occur. 



PORTAL CIRRHOSIS 701 

Course and Prognosis. — The clinical course is essentially chronic; 
it usually lasts not more than two or three years, but its duration, 
after the diagnosis is once made, is more often months than years, 
though a ten to fifteen year course has been observed. Following 
Strieker, Hanot, and Lenhartz, the author excludes all acute cases 
from the category of cirrhosis. Compensatory factors include (a) the 
collateral circulation, which ma\ throw toxins directly on the nervous 
centres and produce symptoms like those of uraemia; (b) hyperplasia 
of the liver cells, which may produce veritable adenomata. As Hanot 
puts it, the diagnosis is based on the condition of the connective tissue, 
but the prognosis depends on that of the liver cells, (c) The kidneys 
may compensate to a small degree. Hale White holds that ascites 
is ominous and that the patient rarely survives the second tapping; 
this does not conform to the author's experience, though ascites is a 
late symptom; the author has seen numerous cases which survived 
frequent tappings, and he has felt justified in excluding peri- 
hepatitis, which White considers explanatory of these cases. The 
prognosis is relatively favorable in subjects under forty years with 
large livers and small spleens. Recovery after a positive diagnosis 
has been made, is possible, especially if the diagnosis is made early. 
In advanced stages death is the usual outcome, although the author 
has seen relative recoveries lasting for five or six years follow adhe- 
sions from multiple paracentesis. 

Death results from hepatargia (cholsemia, acholia), marasmus, 
hemorrhage, ascites, intercurrent pneumonia, or other terminal infec- 
tions; exhausting diarrhoea or vomiting; cardiac, renal, or other com- 
plications (v. s.). 

Differential Diagnosis. — Two classes of conditions require differen- 
tiation : on the one hand, those in which the liver is large ; on the other, 
those in which the liver is small. 

1. When the Liver is Large.— (a) The fatty liver is soft and presents 
no evidences of portal stasis. (To avoid repetition the diseases are 
differentiated later, in tabular form [see page 724].) (b) The amyloid 
liver is hard; the spleen, kidneys, and alimentary mucosa, are almost 
always involved, icterus is very rare, and occurs only when 
amyloid glands at the porta hepatis produce mechanical icterus; 
ansemia is common, (c) Leukemic deposits in the liver cause hepatic 
intumescence, but the blood examination is decisive, (d) Some swell- 
ing of the liver may result from simple icterus, but the history, absence 
of portal stasis, and shorter course, are distinctive, (e) Passive hyper- 
emia from heart or lung disease produces an evenly enlarged tender 
liver, subicterus, and cyanosis. (/) Cancer of the liver is usually 
clearly marked by hard and nodose enlargement, by detection of the 
primary growth {e.g., in the stomach), by icterus, and cachexia; in 
some cases early cirrhosis may simulate cancer, as in a patient whom 
Kahler saw and diagnosticated cancer, though the later course proved 
that cirrhosis was present, {g) In syphilis of the liver the history, knobs , 
and depressions, the more rapid course, greater perihepatitic pain, the 



702 DISEASES OF THE LIVER 

icterus (in 33 per cent.), the findings in other parts, and the results of 
treatment, usually make the diagnosis clear (see Syphilis), (h) Peri- 
cardiac pseudocirrhosis , described by Pick (1896), occurs in young, 
rheumatic, and cardiac subjects, and is characterized by symptoms 
which on the one hand resemble extreme passive congestion of the 
liver, and on the other a capsular cirrhosis; the liver is large and firm, 
there is recurrent ascites without oedema of the extremities, and little 
or no icterus. Its mechanism is disputed; contracting pericarditic 
adhesions may perhaps cause dilatation of the right auricle and vena 
cava inferior, thereby distending the hepatic vein system; or possibly 
the inflammation extends down the cava inferior to the liver; the liver, 
however, is permanently and disproportionately congested, (i) The 
enlarged liver in Banti's disease is cirrhotic, but the spleen is enlarged 
first and there is early splenic anaemia while the cirrhosis and haema- 
temesis occur later. 

2. When the Liver is Small. — The following possibilities should be 
considered: (a) Syphilis, characterized by stellate scars, nodes, and 
pain, (b) Passive congestion; the nutmeg liver may atrophy, but 
anasarca is observed first and usually there are primary and suffi- 
ciently characteristic heart findings, (c) Simple marantic atrophy is of 
little clinical interest; the liver is small, there is no portal stasis, and 
arteriosclerosis is found in other organs, id) Pylethrombosis is charac- 
terized by a rapid onset with swelling of the spleen, severe or repeated 
haematemesis, dilated veins, and rapid recurrence of the ascites after 
tapping; it is due to some special cause, as pressure of a tumor, nearby 
ulcers, suppuration, or gall-stones, (e) Perihepatitis has a very much 
slower course than has cirrhosis; it lasts for years with intermissions, 
and very often results from pericarditis. (/) In chronic peritonitis the 
fluid is turbid, often hemorrhagic, with high specific gravity and many 
leukocytes; it is characterized by absence of symptoms of portal vein 
stasis; there may be pain, fever, and, in the tuberculous form, positive 
results from inoculations; the differentiation of chronic peritonitis is 
considered in detail under Ascites, (g) The peculiar pigmentary 
cirrhosis of haemochromatosis (diabete bronze) was first described by 
Troisier (1871), was named by Recklinghausen, and was particularly 
elaborated by the French school (Hanot, Chauffard). Its symptoms 
are three-fold : (i) cirrhosis (which causes the hemorrhages, indurated 
liver, and enlarged spleen), (ii) diabetes, and (iii) pigmentation of the 
skin, which somewhat resembles Addison's disease. It is thought that 
some toxic substance destroys the red blood cells (haemolysis), and so 
operates on the cells of the liver, pancreas, and other organs, that they 
transform the soluble blood pigment into insoluble hemosiderin. This 
pigment and an iron-free haemofuscin are found in the muscles of the 
intestine, heart, liver, and pancreas, whose cells become pigmented, 
degenerated, and necrotic; the pigment passes into the connective 
tissue of the part. The essential lesion is pigmentation of the liver, 
skin, and pancreas, with the fibrosis of the liver and of the islands of 
Langerhans in the pancreas, which latter causes the diabetes. Diabetes 



PORTAL CIRRHOSIS 703 

has occurred in all but five of the French cases, but seems less common 
in those reported in this country. In Letulle's series of 30, 29 were 
males between forty and fifty years of age. 

Treatment. — 1. Causal Therapy and Prophylaxis. — These have but 
limited applications, save in preventing further injury to the affected 
liver by syphilis and by use of alcohol. All forms of liquors or med- 
icinal tinctures are absolutely interdicted, but too frequently with no 
effect. Syphilitic forms are greatly benefited by appropriate treat- 
ment, which some clinicians think may help all forms of cirrhosis. 

2. Medicinal Treatment. — This is of little value, for cirrhosis cases 
come under observation only after contracting connective tissue has 
already formed. Naunyn has used ten grains of ammonium chloride 
three times daily, but it does not arrest cicatrization. Rolleston believes 
that potassium iodide and ammonium chloride are beneficial in acid 
intoxication (acidosis); he never gives arsenic and salicylates. 

3. Diet. — The diet should exclude rich proteids, for meat is less 
well tolerated than milk. Skimmed milk is best for it contains but 
1 per cent, of fat. Rich or highly seasoned foods are to be avoided. 

4. Symptomatic Treatment. — The same treatment which is insti- 
tuted in chronic gastritis or alcoholism (q. v.) may be indicated. 
Flatulence should be met by calomel in fractional doses, then by salol 
10 grains after each meal, or possibly by beta-naphthol 10 grains, 
though it may cause renal irritation. Diarrhoea should not be checked, 
at least not until the bowels have been thoroughly cleansed, for it is 
eliminative. Unusual splenic intumescence may be treated by purg- 
ing, for it is often a forerunner of hsematemesis. Hsematemesis should 
be treated by absolute rest and by rectal feeding, as in gastric ulcer 
(q.v.); calcium chloride 5 SS to j may be given by rectum for two or 
three doses. Pain is controlled by application of heat locally, by 
calomel, ammonium chloride, and by salines. Nervous symptoms 
necessitate the same treatment as ursemia; namely, laxatives, sweats, 
and transfusions to which sodium bicarbonate may be added as it is 
in diabetes, for the acidosis. 

5. Ascites. — Ascites is seldom benefited by the use of cardiants, 
sweats, diuretics, or purges. Early repeated punctures (see Ascites) 
are beneficial, and may induce adhesions and consequent collateral 
circulation. 

6. Operation. — Talma and Van der Meulen (1889) recommended 
operative measures, which were later amplified in various ways 
and induce a collateral circulation; these consist of sewing the 
omentum to the abdominal wall, rubbing the surface of the liver 
until it is abraded to promote adhesions, and other similar meas- 
ures. In the series collected by Harris, Greenough, and Allyn, 
amounting (in 1903) to 125 cases, about 40 per cent, were improved, 
and about 90 per cent, were alive and in improved health two 
years after the operation. Montprofit found in 224 operations, 
30 per cent, cures. Bunge collected (1905) 274 operations of the 
Talma-Drummond type; the immediate mortality of the operation 



704 DISEASES OF THE LIVER 

was 3.6 percent.; of the surviving cases, 14 per cent, were some- 
what improved, 30 per cent, recovered, and 56 per cent, were not 
improved. Perhaps better results will be recorded if operation is 
resorted to early in the disease, but it must be recalled that the ascites 
and collateral circulation involve vital as well as mechanical considera- 
tions. How the operation is beneficial is still a matter of doubt; its 
mechanical collateral side 'is known; perhaps lessening of venous 
tension in the portal circuit helps the liver cells to a better functional 
activity. 

(0). BILIARY CIRRHOSIS. 

Definition. — A cirrhosis occurring chiefly in adolescence, not due 
to alcoholism, and characterized by fibrosis of a mono- and intralobular 
type, by enlargement of the liver without contraction, by splenic 
enlargement, by chronic icterus without gross obstruction of the bile 
vessels, by paroxysmal fever, and by absence of portal stasis. It is 
also known as Hanot's disease, for it was first clearly described by him, 
in 1876. The term hypertrophic cirrhosis is unfortunate and am- 
biguous. 

Etiology. — Its etiology is obscure. Alcoholism is not a factor. 
Sometimes it apparently results from (a) infection, either an ascending 
cholangitis due to the Bacillus coli or pneumococcus, or an infection 
through the blood stream, (b) Age. Most cases develop between the 
twentieth and thirtieth years of age; it is rare in persons over forty; 
a considerable percentage occurs in the young, especially in residents 
of India (Gibbons, Ghoses). (c) Sex. Over 80 per cent, of adult 
cases are males; in the young the sexes are equally involved. 

Symptoms. — The onset is usually characterized by the early develop- 
ment of icterus and less often by malaise, muscular asthenia, fever, 
splenic pain, dyspepsia, diarrhoea, or abdominal pain. 

Cardinal Symptoms. — 1. The liver is uniformly enlarged, and may 
weigh five to ten pounds (2,000 to 4,000 gm.). Its surface is smooth 
and its edge is fairly even, though somewhat blunt. Its pathological 
characters will be considered under diagnosis. Its dulness extends 
from the fourth rib in the nipple line to the umbilicus or even to the 
iliac crest; it visibly bows outward the right costal arch; and possibly 
by its weight drags down the right shoulder. The gall-bladder is 
not enlarged for there is no obstruction of the large bile-ducts. The 
liver progressively increases in size, often paroxysmally with fever, 
pain over the liver, and increase of the icterus. It never shrinks, except 
when combined with portal cirrhosis. 

2. Icterus develops early, and is constant, permanent, and character- 
istic. It varies in degree though it is usually quite intense. It is due 
to obstruction of the smaller bile vessels; it is not certain that it is 
due to over-secretion of bile (polycholia) or of bile pigments (poly- 
chromia). In extreme cases the skin becomes green or brown. It is 
frequently accompanied by itching, xanthelasma, eczema, and lichen. 



BILIARY CIRRHOSIS 705 

3. The spleen is hypertrophied, is usually increased relatively more 
than the liver, averaging one to two pounds (400 to 1,000 gm.) in weight 
but sometimes actually outweighs it (2,600 gm.), especially in infantile 
forms. It is hard, smooth, and evenly increased in all its elements and 
dimensions. It is often clearly visible and is distinctly palpable. 

Other Symptoms. — Digestive. — The condition of the tongue and of 
the appetite is variable. Nausea, vomiting, dyspepsia, and tympan- 
ites, are uncommon. Diarrhoea is frequent. The normal or diarrhceal 
movements contain bile (in over 90 per cent, of cases). 

Nutritive. — Nutrition is often maintained for years, despite the 
icterus, but wasting subsequently appears. Development is retarded 
in young subjects, and infantilism may be as marked as in cretinism 
or congenital syphilis. Clubbed fingers, from hyperplasia of the soft 
tissues, is not an uncommon development; Gilbert and Lereboullet 
collected 40 cases in 1901. 

Urinary. — The urine is highly colored, bile-stained, and is usually 
increased in amount; its freezing point is high and it may contain 
urobilin, indican, or albumin. 

Circulatory. — The pulse is not slow; the heart is often dilated 
and may reveal a systolic murmur; dyspnoea is frequent, and results 
from pressure on the diaphragm by the swollen liver and spleen; the 
blood shows secondary ansemia, decreased coagulability, and some- 
times moderate leukocytosis. Arthritis and multiple neuritis are rare 
complications. 

Diagnosis. — The following table shows the essential pathological and 
clinical points of contrast with the portal type: 

Portal (atrophic) cirrhosis. vs. Biliary (hypertrophic) cirrhosis. 

1. Etiology: alcoholism; over forty Infection; under forty years. 

years of age. 

2. Liver, large or small (possibly both Always large and to greater degree. 

in succession); shrinks often. Never shrinks in pure forms. 

Granulations : larger. Small; very fine. 

Yellow. Dark, icteric, green. 

3. Connective tissue and inflammation Begins in lobule (monolobular or insular) 

ensnaring several lobules (mul- around smaller bile radicles (chol- 

tilobular or annular), and around angitis) in early stages at least, later 

portal vein radicles. less clear. 

Distinction between connective tis- Not sharp, 
sue and lobules sharp. 

Connective tissue, firmer, more More delicate, reticular, richer in cells, 
fibrous; more elastic tissue. embryonal. 

Scar-like and contracts. Does not contract (elephantiasis hepa- 

tis). 

4. Liver-cells, early fatty, degenerate, Seldom fatty, remain normal for long 

disappear. time, may regenerate, more pig- 



45 



mented. 
(Concluded on page 706.) 



706 DISEASES OF THE LIVER 

Portal (atrophic) cirrhosis. vs. Biliary (hypertrophic) cirrhosis. 

5. Portal system cannot be injected by Easily injected. 

portal vein. 

6. Bile vessels. (Proliferating bile vessels in biliary form are not characteristic, 

and are probably merely compressed rows of liver cells.) 

7. Icterus infrequent, a complication; Constant throughout course, and still 

when present, usually catarrhal. the stools contain bile. 

8. Ascites rarely absent in advanced Absent in all (except mixed forms). 

cases. 

9. Collateral circulation — usual. Never. 

10. Hamatemesis, frequent, early, Very rare, late, cachectic, or toxsemic. 

mechanical. 

11. Constipation usual. Diarrhoea quite frequent. 

12. Duration of two to three years. Five to ten years. 

Death results from ha3matemesis,nephri- Rare; death from hepatargia (so-called 
tis, tuberculosis, peritonitis. cholsemia) with fever, nervous symp- 

toms, delirium, typhoid state, coma. 

It is a rare affection, and a diagnosis of biliary cirrhosis is too 
often made. If the cardinal features under its definition are borne in 
mind, it can usually be separated with ease from the following affec- 
tions: (a) In hepatic cancer, the subject is older and more cachectic, 
the course is shorter, there is no splenic tumor, the primary growth 
e.g. , in the stomach, may be recognized, the liver often presents ir- 
regularities, the neoplastic obstruction of the bile duct produces 
acholic stools, and obstruction of the portal vein causes ascites. (6) 
Multilocular echinococcus (q.v.) also produces icterus, and enlarged 
liver and spleen, but is exceedingly uncommon, (c) Fatty and amyloid 
liver are unattended by jaundice, and in amyloidosis the enlargement of 
liver and spleen is usually associated with albuminuria, diarrhoea, 
oedema, and cachexia, (d) Obstruction of the bile ducts may produce an 
enlarged gall-bladder (v. Icterus) ; the stools are usually but not neces- 
sarily acholic (e. g., in stone of the common duct). The spleen is not 
large. In this connection it may be stated that some recognize a (so- 
called) biliary cirrhosis due to chronic obstruction of the duct, as 
described by Charcot and Gombault in 1876; Osier and Hale White 
properly hold that simple mechanical obstruction never causes fibrosis, 
though it may follow ascending cholangitis. The liver is far less large 
in this obstructive type and is seldom hard, (e) In hsemochromatosis 
and pigmentary cirrhosis, icterus is absent and glycosuria is present in 
about 85 per cent, of cases. (/) For Banti's disease, see diagnosis of 
portal cirrhosis. (See page 724.) 

Treatment. — The treatment is that of portal cirrhosis; no means 
are known which stop the formation of connective tissue. A generous 
diet may be given. Cold and dampness are especially to be avoided. 
Calomel in small doses (grain io to -& t.i.d.) may be given for weeks 



ABSCESS OF THE LIVER 707 

at a time, and salol, the salicylates, and simple salines, are some- 
times beneficial. Operative relief is suggested by drainage of the gall- 
bladder, but in the reported cases the true biliary cirrhosis is often 
confused with obstructive icterus: operation might be helpful in 
biliary cirrhosis due to ascending infections. 



(D). ABSCESS OF THE LIVER. 

Suppurative hepatitis may be considered as a local affection, though 
it is sometimes a part of septicopyemia (q. v.). Virchow found it in 1.5 
per cent, of autopsies. Ninety-seven per cent, occurs in males. 

Varieties. — 1. In the septic type, 53 to 55 per cent, of cases (Baren- 
sprung and Luda) the hepatic artery is the usual carrier of infection ; 
the primary focus is usually in the external parts, especially the skull 
(Hippocrates). It may result from osteomyelitis, external inflam- 
mations, pulmonary abscess or gangrene, putrid bronchitis, and, less 
often, from ulcerative endocarditis. Liver abscess occurs in 15 per cent. 
of cases of surgical septicopyemia (Barensprung). Infected thrombi 
in the peripheral veins may become detached, infarct the lungs, and 
thence reach the arterial circulation. In rare cases infective material 
may fall back from the cava into the hepatic vein; this is known as 
retrograde embolism. The bacteria are those enumerated under 
sepsis — the pyogenic organisms, pneumococcus, colon, and typhoid 
bacillus. 

The symptoms of septic abscess are not distinctive because, first, they 
are obscured by the general toxaemia, and, second, the multiple abscesses 
when scattered through the liver usually produce few decisive local 
symptoms. The liver enlargement is uniform and is generally indis- 
tinguishable from the cloudy swelling of sepsis; fluctuation is rare; the 
portal circulation is rarely obstructed; pain and tenderness are usually 
present; jaundice is inconstant; the spleen is swollen from sepsis ; the 
course is rapid. The septic type may occasionally, and the traumatic 
often, consist of a single large abscess. 

2. The second variety results from infection through the tributaries 
of the portal vein (31 per cent.) (Kelsch contends that 85 per cent, of 500 
liver abscesses were due to dysentery) ; it has been known since Mor- 
gagni's time and is clinically the most important type. Any ulcerative 
or suppurative affection in parts containing these branches may be 
causal, for instance, amoebic dysentery (the most frequent cause), 
appendicitis (in 6 per cent, of its fatal cases), neglected hemorrhoids, 
gastric ulcer or cancer, and disease of the bile vessels, the vessels of 
which are portal tributaries. Pyogenic organisms, the Amoeba dysen- 
teric, foreign bodies (as fish-bones, pins, liver flukes, and parasites) , may 
enter by the portal circulation. Pus organisms may enter and infect 
tuberculous, echinococcic, or actinomycotic foci, of which latter 40 cases 
are recorded. The form of lesion varies ; (a) there may be the solitary or 
tropical liver abscess, which will be considered separately, or (b) there 



708 DISEASES OF THE LIVER 

may be suppurative pylephlebitis, which is less a suppuration of the 
liver substance than an extension of inflammation in the portal 
vein itself, and follows in a dendritic fashion through all of its intra- 
hepatic ramifications; its branches are distended and present small 
accumulations of pus, which may appear as yellowish foci through the 
capsule, but show more clearly on section as portal vein suppuration; 
the whole liver may be involved, or certain areas may be exempted by 
total thrombotic occlusion of the larger branches. In some cases the 
purulent thrombophlebitis may be traced back to the original lesion in 
the stomach or intestine ; the liver is enlarged but the diagnosis is rarely 
more than a probable one. 

3. The third variety is infection by the bile vessels (10 per cent.), in 
which an ascending cholangitis (q.v.), often calculous in origin, pro- 
duces multiple small abscesses through the liver substance; this is 
rather similar in appearance to the pylephlebitic form. These three 
varieties account for 94 to 96 per cent, of cases of liver abscess. 

4. The fourth variety is infection in infants through the navel, and 
is an infrequent occurrence. 

5. The fifth variety is direct involvement of the liver by contiguity, 
which may occur in various diseases, as in suppuration of the gall- 
bladder or ulcer of the stomach. 



Solitary or Tropical Abscess. 

The abscess is solitary in 75 per cent, of cases; in 11 per cent, there 
are two, and in 14 per cent, more than two, foci. Twenty to 30 per cent, 
of cases of amoebic dysentery, by far the most common cause, is com- 
plicated by liver abscess. Amcebic abscess may even occur without 
intestinal ulceration, though amoebae are found in the stools; in 5 out of 
27 of Futcher's cases there were no intestinal symptoms. Over 50 per 
cent, of tropical abscesses operated on in England by Manson con- 
tained amoebae. Shiga's bacillary dysentery is rarely a cause. Single 
abscess may occasionally occur from trauma, pyaemia, typhoid (pro- 
bably pyaemic), or in hydatid cysts. It occurs chiefly in the tropics, 
though it is seen in the Southern states and sometimes in the North. In 
the tropics it is thirty-five times as frequent in Europeans as in the natives ; 
alcoholism and a rich diet are particularly predisposing factors; 97 per 
cent, occurs in males and 50 per cent, in those between twenty and 
thirty years of age. 

Pathology. — Amoebae reach the liver by the portal vein, and cause 
necrosis by their toxins; this is followed by suppuration, which may 
cause single or multiple foci. The smaller and sometimes the miliary 
foci contain glairy, gelatinous, translucent fluid; the larger foci contain 
white, yellow, green, reddish (like anchovy sauce, Budd), or chocolate- 
colored fluid, which may be serous, bloody, or viscid. Lafleur and 
Councilman consider that the absence of leukocytes in the wall and 
contents is pathognomonic of amoebic abscess. Red disks and 



SOLITARY OR TROPICAL ABSCESS 709 

necrotic liver cells are frequent. As Kartulis pointed out, the pus is 
usually sterile. The amoebae are more abundant in the abscess wall 
than in its contents, and may be found in the vessels outside of the 
abscess. In contrast to other abscesses, the walls of the amoebic type 
are soft, ragged, and produce but little granulation tissue or fibrous 
encapsulation. 

Symptoms. — Absence of all symptoms (latency) occurs in 13 per 
cent, of cases. Symptoms may be classified as (1) septic, (2) hepatic, 
and (3) other symptoms and complications. 

1. Septic Symptoms. — (a) Fever is the most important; it is re- 
mittent or intermittent, is less often continuous, and in chronic cases 
there may be a normal or subnormal register, (b) Rigors and sweats 
are frequent, (c) Leukocytosis occurs in about 50 per cent. only. In 
43 uncomplicated dysentery cases, the leukocyte count was above the 
average count of the abscess cases in 23.4 per cent. (Futcher). (d) The 
pulse is small and frequent, (e) Progressive emaciation is usual, and 
the facies is a combination of hectic, depression, subicterus, and 
cachexia, which is difficult to describe. (/) The urine is febrile and 
may contain albumin or albumose. 

2. Hepatic Symptoms. — The liver is enlarged from the abscess and 
from sepsis. The abscess in 70 per cent, is located in the right lobe; 
Serege by injections has shown that venous blood from the pancreas 
and intestine is conveyed to the right lobe (whence the right lobe is 
chiefly involved in intestinal ulceration or cancer), while the blood from 
the stomach and spleen finds its way to the left lobe. The enlargement 
is more often upward than downward, wherein abscess differs from 
cancer and resembles echinococcus. The swelling is often localized, 
occasioning a dome-like dulness on the upper border of the liver (Fre- 
richs) ; in other cases there is bulging of the lower interspaces or of the 
hypochondrium. In very large abscess the entire organ is greatly 
swollen, as in one reported case of an abscess which contained 2-J- gallons 
of fluid. When it occurs below the ribs, fluctuation in the liver, and, less 
often, oedema of the abdominal wall, may be noted. The liver con- 
sistence may be increased at first, (b) Pain is usually present, and is 
due to increased weight or to capsular tension and inflammation; 
perihepatitis or sometimes pleurisy may cause a friction rub which 
results from fresh inflammation; or may cause adhesions in more 
chronic cases. The patient usually lies on the back or right side to 
avoid the pain caused by sagging of the liver which occurs when he is 
in the left lateral decubitus. Pain is present in the right shoulder in 17 
per cent., being reflected from the phrenic filaments on the liver con- 
vexity along the phrenic nerve to the acromial branch of the fourth 
cervical nerve, with which the phrenic nerve is connected; in rare cases 
the deltoid may waste ; the left shoulder is seldom the seat of referred 
pain, (c) Tenderness over the liver is usually circumscribed, but 
sometimes general. The right rectus muscle is frequently tense. 

3. Other Symptoms; Complications. — (a) Icterus occurs in 16 per 
cent, of cases ; it may be slight from sepsis or from compression of some 



710 DISEASES OF THE LIVER 

bile ducts within the liver, or it may be complete from catarrh of the 
common duct, (b) The spleen is seldom enlarged, except from a causal 
septicopyemia, (c) A dry spasmodic reflex cough may be noted 
(tussis hepatica). (d) Rupture may be the first sign of abscess of the 
liver. In TVaring's 300 cases, 56 per cent, remained intact, 16 per cent, 
were operated on, and 28 per cent, ruptured, (i) It occurs into the 
lungs in about 10 per cent, (average of the figures of Waring and Cyr); 
abscess of the lung results more often from direct rupture than from 
indirect metastasis by the hepatic vein. The patient presents signs of 
lung abscess (q. v.) and expectorates chocolate-, anchovy- or cream- 
colored pus containing amoebae, often liver and lung tissue, haematoidin 
crystals, and perhaps bile. Death may be caused by profuse haemop- 
tysis, (ii) Rupture into the right pleura (6 per cent.) causes empyema. 
Pleurisy, both fibrinous and serous, may also occur without rupture, 
resulting from attenuated infection passing through the lymphatics of 
the diaphragm; a right-sided friction rub, serothorax or empyema, 
should always suggest the possibility of an hepatic etiology, (iii) 
Rupture into the peritoneum (6 per cent.) causes localized or diffuse 
peritonitis. A subacute serofibrinous peritonitis rarely results, but the 
author has seen this form, as well as an encapsulated serous effusion, 
cover the convex and anterior surface of the liver, (iv) Rupture into 
the bowels (colon 2 per cent, and duodenum 1 per cent.) causes pus to be 
voided, sometimes in large amounts, by the stools, (v) Less frequent 
are ruptures into the stomach, pericardium, pelvis of the kidney, portal 
or hepatic vein, inferior cava, bile vessels, or abdominal wall, (e) Less 
frequent complications are pyloric obstruction (from abscess of the left 
lobe), pseudorheumatism or clubbed fingers (from toxaemia), cerebral 
abscess, and intestinal obstruction. 

Diagnosis. — Diagnosis is based on (a) an etiological factor; (b) 
symptoms of sepsis; (c) hepatic signs, localized enlargements, pain, and 
tenderness; the x-rays may be useful when there is bulging of the 
convexity covered by the lung; (d) exploration with the aspirating 
needle, which is usually without danger. The author has seen, as a 
result of puncture, two deaths from peritonitis and one from an enor- 
mous hemorrhage into the peritoneal cavity in a case of abscess with 
intense icterus; puncture should be performed only when an operation 
can be done immediately after pus is found; pus is far less often found 
in multiple small abscesses than in the large solitary form. 

Differentiation. — Five types of liver abscess are often described; 
(a) the latent, (b) typhoid (see Typhoid Table, including Sepsis and 
Malaria), (c) malarial, intermittent, (d) phthisic, and (e) a type 
declared by rupture, either pulmonary, peritoneal, or pleural. 

Subphrenic abscess simulates pneumothorax (q.v.) rather than liver 
abscess, because of the presence of tympany; in its etiology and treat- 
ment (see Localized Peritonitis) it resembles liver abscess. In gall- 
stones, with or without suppuration, the fever usually occurs in par- 
oxysms separated by fairly long intervals, jaundice (if present) is apt 
to become more intense with the fever, the history is different, and 



TUMORS OF THE LIVER 711 

marasmus is rare. Abscess of the abdominal wall shows no respiratory 
excursion in the exploratory needle introduced into the abscess. Differ- 
entiation from pleurisy, echinococcus , and cancer of the liver, is consid- 
ered under these topics and also in the differential table (page 724). 
Prognosis and Treatment. — Ninety-three per cent, of unoperated 
cases die from unfavorable ruptures (peritoneal, pleural, pulmon- 
ary), sepsis, marasmus, and amyloid disease, which may occur after 
weeks or months. It is possible for an abscess to desiccate or to heal 
after breaking into the lung or bowel but this cannot be depended 
upon. The treatment is solely operative; Solonoff (1903), quoted by 
Rolleston, in a collection of 1,094 cases estimates the mortality at 30 per 
cent. • 

(E.) TUMORS OF THE LIVER. 

Tumors of the liver are chiefly carcinoma. Benign tumors possess 
little clinical interest, as fibroma, lipoma, teratoma, adenoma, or 
angioma, which latter is more frequent in the liver than in any other 
organ. Single adenoma may develop from the liver cells or bile ducts; 
multiple adenomata occur chiefly in cirrhosis. (Three cases are re- 
ported of adrenal "rests/') Sarcoma is rarely primary, there being 
hardly twenty clear cases on record; it may develop from the connec- 
tive tissue, endothelium of the lymph or bloodvessels or Kupfer's cells, 
as a single primary tumor, multiple primary tumors, diffuse infiltration, 
or possibly as a primary melanotic growth, which, however, is almost 
always secondary to melanotic sarcoma of the eye or skin. 

Cancer of the liver occurred in 2.7 per cent, of Virchow's autopsies, and 
ranks third among internal cancers: the frequency of cancer locali- 
zation varies somewhat; the usual order of frequency is cancer of the 
uterus, stomach, mamma, and liver; Eichhorst's order is uterus, 
stomach, mamma, oesophagus, and liver, (a) Primary cancer is 20 to 48 
times as infrequent as secondary cancer; 66 per cent, occurs in males. 
It originates from the liver cells (88 per cent.) or bile vessels (12 per 
cent.). The main forms are observed (i) as sharply outlined massive 
local swelling (in 23 per cent, of Eggel's 163 cases reported in 1901); 
(ii) as sharply demarked multiple nodes of moderate size (in 65 per 
cent.) of which one of the tumors is primary and the rest secondary; and 
(hi) as diffuse infiltration, fusing with the parenchyma (in 12 per cent.) ; 
(iv) there is a fourth form, which develops in hepatic cirrhosis. 
The writer has seen primary cancer develop from an hepatic cyst. 
Metastases occur in 66 per cent (Eggel). (b) Secondary cancer 
results from primary cancer in the stomach (33 per cent.), in the colon 
(12 per cent.), oesophagus, pancreas, gall-bladder, uterus, ovaries, and 
mamma, by metastasis or extension by contiguity; cancer cells may 
enter by the portal vein and hepatic artery, or much less frequently by 
retrograde metastasis through the hepatic vein; the lymph vessels do 
not carry cancer infection, as their current flows from within to without 
the liver. Their structure is that of the primary type. 



712 DISEASES OF THE LIVER 

Symptoms. — 1. Hepatic Symptoms. — (a) The liver enlarges rap- 
idly; it may increase to six or eight times its normal size and may weigh 
30 to 40 pounds. Its edge is uneven though fairly sharp; on its surface 
are lumps which may present a central umbilication. Great unevenness 
is more characteristic of secondary than of primary tumor in which the 
liver is more uniformly swollen. The enlargement is chiefly downward 
though the liver is sometimes high because of ascites, tympanites, or 
adhesions. Xodules in the falciform ligament may be felt near the 
navel or linea alba. Sudden increase in size occasionally results from 
hemorrhage which is due to icterus. There is no enlargement when the 
nodules are few and small, and the liver is smaller than normal in 10 per 
cent, of cases (liver cirrhosis plus malignant adenomata), (b) Hepatic 
pain is more conspicuous than in any other liver lesion. It may be 
caused by capsular tension, increased weight, perihepatitis, pleuritis, or, 
less frequently, from rupture of tumor particles into the bile passages, 
which may simulate the pain of gall-stones, (c) The liver is often 
tender, (d) Exceptionally pulsation may be transmitted from the 
aorta, or there mav be a venous hum over the liver. 

2. Cachectic Symptoms. — These are adynamia, marasmus, anor- 
exia, secondary anaemia, leukocytosis (in any carcinoma, but especially 
in hepatic), insomnia, stupor, and illusioDS. Cachexia probably results 
from the katabolic toxins elaborated by the tumor, and possibly also 
from hepatic insufficiency (v. Cirrhosis). Fever may result from the 
tumor alone, from cholangitis, and from secondary or terminal in- 
fection. The rare peripheral neuritis and some of the urinary findings 
may be referred to cachexia. In some rare cases there may be no 
cachexia. 

3. Compression Symptoms. — (a) Jaundice occurs in 50 to 90 per 
cent, and more frequently in secondary than in primary cancer. It 
usually results from mechanical pressure on the larger bile ducts by the 
tumor or by carcinomatous glands. Pressure on the ducts within the 
liver often produces moderate jaundice, and some bile then appears in 
the stools; complete icterus may result from catarrhal or calculous 
obstruction (especially significant when there is no ascites) or from 
pressure by enlarged lymph glands. Exceptionally the tumor grows into 
and along the bile ducts, thereby totally obstructing them, (b) Ascites 
is present in 50 per cent, of cases. It is usually moderate in degree and 
results from pressure on the portal vein or its larger branches, periton- 
itis, or portal vein thrombosis (pylethrombosis) ; occasionally it is due 
to the cirrhotic form of cancer, growing of the tumor into the hepatic or 
portal vein, rupture — perhaps with syncope and great hemorrhage — 
of a cancer nodule into the peritoneum, or rarely to plugging of the 
liver capillaries by the pigment of a melanosarcoma (Hektoen and 
Herrick). A collateral circulation may develop. Friction from peri- 
hepatitis may be noted. The fluid is usually serous or hemorrhagic, less 
often adipose, chylous, or opaque (v. Cirrhosis), and very rarely contains 
melanin (sarcoma), (c) Other compression symptoms include splenic 
tumor from marantic pylephlebitis or pressure on the splenic vein (11 to 



TUMORS OF THE LIVER 713 

17 per cent.), hydronephrosis, vomiting from pyloric obstruction, 
dyspnoea from pressure on the heart and lungs, and oedema from pres- 
sure on the cava inferior. 

4. Other Symptoms. — The cervical glands are seldom swollen unless 
there is coincident gastric cancer. Carcinomatous nodes may appear 
at the navel or even in the skin over the liver, which is due to regional 
extension. In liver cancer combined with cirrhosis any cirrhotic 
symptom may occur. The urine shows increased destruction of the 
tissue nitrogen; the nitrogenous extractives are increased from the 
normal 0.6 or 0.8 per cent, to 13 or 23 per cent. Acetone, and diacetic, 
lactic, beta-oxybutyric acids, and indican, are not infrequently present. 
The urine is decreased, high-colored, and is often icteric. Albuminuria 
is due to stasis and toxaemia (Teissier speaks of hepatogenous albu- 
minuria). The urea may be decreased; leucin and tyrosin are some- 
times present. Mel anuria (sarcoma) is sometimes detected by adding 
to the urine a solution of ferric chloride ; the pigment exists in the blood 
as melanin or melanogen,the latter of which is precipitated as the urine 
stands, or by the addition of some oxydizing agent as nitric acid; its 
presence nearly always indicates involvement of the liver by a melanotic 
tumor; melanuria has often been confounded with indicanuria and al- 
kaptonuria. 

Diagnosis. — The chief features are rapid enlargement of the liver, 
irregular tumors, pain, icterus, ascites, cachexia, and, in 50 per cent, of 
cases, the recognition of the primary tumor. Other causes of liver 
enlargement must be considered as in cirrhosis. (See also Differential 
Table, page 724.) Icterus with ascites is always suggestive. In some 
cases liver involvement is not suspected. The differentiation is as 
follows: (a) Cirrhosis (see both forms), (b) Syphilis (q.v.), as a rule, 
produces smaller, harder tumors, of less rapid growth, which are more 
often associated with splenic tumor and albuminuria, much less 
often complicated by ascites or icterus, and respond to mercury and 
iodide, (c) The amyloid liver is equally large and but seldom causes 
confusion except when complicated by gummata; amyloidosis of the 
spleen, kidney, and intestines, usually co-exists with amyloid liver, (d) 
Hydatid cysts develop more slowly and earlier in life, and cachexia 
appears late if at all. Multilocular echinococcus produces enlarged 
liver, ascites, and icterus, but the spleen is also enlarged; puncture may 
give characteristic findings; the affection is very rare, (e) Liver 
abscess is seldom accompanied by icterus and ascites; puncture often 
excludes those doubtful cases of cancer in which there is fever, leu- 
kocytosis, and semifluctuation of the necrotic neoplastic nodes. (/) In 
congested liver the causal heart or lung disease, the symmetrical liver 
swelling, other signs of stasis, diffuse tenderness, and subicterus to- 
gether with cyanosis, are distinctive, though the writer knows of four 
cases of nutmeg liver in which the stasis unaccountably caused more 
local than general hepatic enlargement, (g) The corset liver can be 
easily differentiated. The general symptoms, such as cachexia, and the 
compression symptoms of cancer, are duly considered, (h) Cancer of 



714 DISEASES OF THE LIVER 

the stomach (q.v.) is readily differentiated by its peculiar chemism and 
its signs of stagnation; gastric cancer may, of course, be the cause of 
hepatic involvement, (i) Renal or adrenal tumors are covered by the 
inflated colon, encroach less upon the thorax, evert the ribs less, have 
(less or) no respiratory excursion, and often are separable from the liver 
by an intervening strip of tympany. 

(j) Differentiation between primary and secondary tumors is difficult, 
yet is somewhat irrelevant according to Leube, as the causal growth 
leading to hepatic metastasis is latent in 50 per cent, of secondary 
tumors, and great caution should be exercised in diagnosticating 
primary liver tumor. The following characteristics of primary tumor 
are of relative importance, though subject to many exceptions: the 
solitary tumor, its rapid growth, infrequent jaundice and ascites, 
lesser emaciation, and more rapid course, which results in death, ac- 
cording to Hale White, in less than four months. Secondary tumors 
cause death within seven months, from cachexia, ascites, and inter- 
current pneumonia. 

Treatment. — Treatment is entirely palliative for the pain and 
ascites except when, in very exceptional cases, early operation (for 
primary growths) can be performed. Luecke reported the first recovery, 
which afterward proved to be a gumma; his operation was followed 
by a few others, the cases of Nothnagel, Keen, Mayo Robson, Barde- 
leben, D'Urso, Israel, Hochenegg, Heidenhain, von Bergmann, and 
others, which included recovery from cancer, sarcoma, and malignant 
adenoma. 

(F). ECHINOCOCCUS CYSTS OP THE LIVER. 

The parasite will be considered under Animal Parasites and we will 
here consider the symptoms of its hepatic localization, which consti- 
tutes about 60 per cent, of echinococcus disease; though the adult 
parasite occurs in the intestine of the dog, wolf, fox, and jackal, its 
cystic form occurs in man alone. 

Symptoms. — Fully half the cases of liver echinococcus are clinically 
latent. Cases with symptoms show the following liver findings: (i) A 
cyst on the lower border or anterior surface may produce a visible, 
palpable, round and smooth bulge which everts the costal arch or much 
less often affects the left lobe. In some cases cysts in the right lobe lead 
to compensatory hypertrophy of the left lobe, which may equal the size 
of a normal liver. The tumor is as large or larger than an orange. It 
is tense, elastic, semi-solid, and on percussion is dull; it may fluctuate 
and give the "hydatid thrill" of Briancon and Piorry, a vibration 
which is elicited by laying three fingers over the cyst and tapping with 
the middle one ; the thrill is not a frequent finding, and may also occur 
in ascites and sarcoma. The cysts rarely contain gas, which is due to 
the Bacillus coli. In large cysts (36 to 70 pints are reported to have been 
found) the liver may tip so that the right lobe is lower and the left higher 
than normal, (ii) Cysts on the convexity crowd the diaphragm up- 



ECHINOCOCCUS CYSTS OF THE LIVER 715 

ward, may cause symptoms resembling those of pleurisy (q.v.), pro- 
duce a dome-like dulness as in cancer, and may compress the lung or 
even the heart, (hi) Liver pain and tenderness are rare without sup- 
puration, which may induce perihepatitis; pain, as in cancer, may be 
referred to the right shoulder. Pleuritic pain follows rupture into the 
pleura, (iv) Exploratory puncture (Recamier and Cruveilhier) is 
dangerous, because severe nervous toxaemia and cardiac collapse may 
follow, as described under echinococcus of the lung and pleura, where 
also the finding of pus, the characteristic membrane, chemical contents, 
and hooklets, are enumerated. 

Rupture may occur into the lungs (in 11 per cent, of liver echino- 
coccus); it may simulate phthisis or gangrene of the lungs; cysts may 
rupture into the pleura, peritoneum, kidney, stomach, bowel, bile 
passages, pericardium, portal or hepatic vein, and cava inferior; heart 
embolism or external rupture may occur. 

Pressure symptoms are rare, as icterus (5 per cent.), pyloric ob- 
struction, ascites, albuminuria, caput Medusa, or oedema of the legs. 
Dyspnoea may result from pressure on the lungs, or vomiting from 
pyloric stenosis. In some cases there is a distaste for fat or meat. 
Hemorrhage from the alimentary tract is rare. The blood is usually 
normal, though the eosinophiles are usually increased in nonsup- 
purating cysts. Urticaria may occur after puncture or rupture, or 
without either incident. 

Diagnosis. — Diagnosis depends on (a) the history of the case, 
including close contact with dogs; (b) the smooth, round tumor; (c) 
the thrill; id) slow development; (e) the infrequency of constitutional 
disturbance, pain and fever; in other words, the predominance of 
the signs over the symptoms. 

Differentiation. — (a) From other liver cysts; the small cysts which 
occur in cirrhosis and in obstructive icterus are of no clinical im- 
portance. Simple serous cysts may, in exceptional cases, hold several 
(even 13) pints; they rarely cause symptoms, rupture or hemorrhage. 
Diffuse, congenital, cystic disease may cause dystokia; in adults also 
the cysts are probably congenital or developmental in origin, and are 
associated with cystic kidneys, in 4 to 27 per cent, of cases (Lejars, 
Luzatta, and Johnson). Moschcowitz (1906) collected 85 cases of 
non-parasitic cysts of the liver; they are usually multiple and sub- 
capsular and are often associated with other congenital anomalies 
such as hare-lip, spina bifida, hypospadias, or supernumerary fingers. 
He concludes that (i) they are always associated with congenitally 
aberrant bile ducts; (ii) they are embryonal " rests "; (hi) the cysts 
are due to inflammatory hyperplasia of these ducts or to congenital 
obstruction in them. Hoffmann reported 18 operated cases, (b) 
Malignant disease causes cachexia more pain (than does echinococcus), 
multiple tumors, ascites, and icterus, (c) Syphilis of the liver (q.v.) 
more often causes albuminuria or splenic tumor, and responds to 
antisyphilitic remedies, (d) From pleurisy; the .r-rays may show the 
localized tumor on the liver convexity; but the upper line of pleuritic 



716 DISEASES OF THE LIVER 

dulness is much less often convex upward; there may be thoracic 
symptoms, as haemoptysis, when there is rupture into the lung; care- 
ful examination of the sputum or aspirated fluid shows the diagnostic 
hooklets. (e) In rare cases a pendulous, pedunculated, movable cyst 
(v. Frerichs) may necessarily resemble pancreatic cysts, enlarged 
kidney, gall-bladder or ovarian cyst. Rupture into the bile passages 
may simulate the pain of gall-stones. (/) Liver abscess is usually 
distinguished with ease, though one may remain in doubt in cases 
of suppurating cysts; the eosinophiles are not increased in liver 
abscess; both conditions are strictly surgical. (See table page 724.) 
Prognosis. — The prognosis depends largely on whether surgery is 
invoked. Cysts may, however, calcify or indurate spontaneously. 
According to Cyr, the mortality of rupture into the peritoneum is 
90 per cent., into the pleura 80 per cent., bile ducts 70 per cent., 
bronchi 57 per cent., stomach 40 per cent., intestines 15 per cent., 
and externally 10 per cent. 

. Treatment. — When drainage by the trochar is performed (Hippoc- 
rates), it is said that 45 to 77 per cent, of cases recover, and some 
are benefited by injection of iodine or electrolysis. A few die sud- 
denly from a toxalbumin, which is formed when the parasite dies; 
it causes urticaria, convulsions, cardiac failure and other symptoms 
similar to those produced by myrtilotoxin in mussel-poisoning. Direct 
surgical intervention is attended with the least risk. Prophylaxis is 
necessary, such as the burning of slaughter-house offal and avoiding 
close contact with dogs. 

Multilocular or Alveolar Echinococcus. 

This form is due (see Animal Parasites) to another parasite; it 
is extremely infrequent and only about 100 cases are recorded. 

Symptoms. — The right lobe of the liver alone is involved in 65 
per cent, of cases, and the left alone in 10 per cent. The liver is 
hard (from fibrosis), nodular and seldom fluctuates. This rare affec- 
tion is attended by splenic tumor (90 per cent.), icterus (80 per cent.), 
dyspepsia, ascites and, less commonly, by fever, polyuria, collateral cir- 
culation, gastro-intestinal hemorrhage, late emaciation (cachexia), and 
metastases in the heart and lungs by way of the lymph or blood- 
vessels ; or death may occur after a number of years from cholsemia or 
hemorrhages. The diagnosis is very difficult, though it is sometimes 
aided by exploratory puncture, and the most frequent confusion is 
with cancer of the liver. The only hope of recovery is in extirpation, 
which has been successfully done by Terillon, Bruns and others. 



FATTY LIVER 717 



(G). FATTY LIVER. 

The term "fatty liver" (hepar adiposum) includes fatty infiltration 
and fatty degeneration; as a distinction between them is of more 
speculative than clinical interest, they may be considered together. 

Etiology. — (a) Obesity and (b) decreased oxygenation from carcinosis 
or any other cachexia, rickets, profound or pernicious ansemia, phthisis, 
cardiac stasis and kindred causes may produce fatty liver, (c) Tox- 
aemias, as tuberculosis, the acute specific infections, infantile diarrhoea, 
acute yellow atrophy, and suppuration, (d) poisons, as phosphorus, 
alcohol, arsenic, or chloroform, and (e) local diseases of the liver, as 
cirrhosis or nutmeg liver are etiological factors. 

Pathology. — The fat, which is normally found in the liver up to 
2 to 5 per cent, of its weight, may amount to over 40 per cent. The 
liver is enlarged, and may weigh as much as 12 pounds or 4,500 gm. 
Its surface is smooth, its edges are rounded, its consistence is decreased 
and its color is yellow. On section it is anaemic, yellow and smooth, 
though the lobules may be slightly prominent. The color is yellow 
when oleic acid predominates, and pale when there is more palmitin 
and stearin. Slight quantities may be detected only on microscopic 
examination. When cut with a warm knife the fat may be seen on 
the blade. Microscopically, fat is seen which, in fatty infiltration, is 
located principally in the periphery of the lobule and obscures the 
liver cells; when the fat is dissolved by ether, the normal liver cells 
are clearly seen. In fatty degeneration, fat forms at the expense 
of the liver cells, i.e., the percentage of albumin is decreased. The 
statement that fatty infiltration occurs in large globules and fatty 
degeneration in smaller ones is not wholly correct. Pathologists have 
lately been inclined to consider infiltration of more importance than 
degeneration. 

Symptoms. — (a) The positive findings are as follows: the liver is 
symmetrically enlarged and smooth and rarely extends below the navel. 
Its edge is rounded, soft and can usually be palpated, even in obese 
persons, (b) The negative findings are absence of pain, tenderness, 
icterus, splenic tumor, ascites or gastro-intestinal hemorrhage. The 
urobilin may be decreased. 

The diagnosis is easily made, and liver stasis, amyloid degeneration, 
and cirrhosis can be readily excluded (see Differential Table, page 
724). The treatment is merely that of the causal obesity or of other 
factors involved. 

(H). AMYLOID LIVER. 

Amyloid degeneration was first clearly described by Rokitansky. 

Etiology. — (a) Ulcerative tuberculosis of the lungs or bones causes 
over 50 per cent, of amyloidosis. (b) Inveterate syphilis, particularly 
the ulcerative and osseous types, produces about 25 per cent, of amy- 



718 DISEASES OF THE LIVER 

loid disease, (c) Chronic suppuration, in connection with, or inde- 
pendently of, the above causes, has become uncommon since the 
introduction of asepsis and antisepsis. Krawkow produced amyloid 
degeneration experimentally by inoculations of the staphylococcus. 
(d) As exceptional causes, intestinal ulcerations, exhausting diarrhoeas, 
rickets, leukaemia, pseudoleuksemia, and ulcerating neoplasms may 
be mentioned. Seventy-eight per cent, occurs in males (Frerichs). 

Pathology. — Amyloid degeneration is much less frequent in this 
country than in Europe. Its localization, in order of frequency, is 
in the spleen, kidneys, liver and intestines. The liver is uniformly 
enlarged and may weigh 13 to 16 pounds (5 to 6,000 gm.), even in a 
child. It is hard, smooth and very pale. Its edges are more blunt 
than normal, though somewhat sharp. On section the general appear- 
ance is waxy, speckled, somewhat resembling raw ham, the edges are 
slightly translucent and the lobules are indistinct. If a thin slice is 
placed in diluted LugoFs solution, the amyloid areas assume a brown 
color (Virchow), the name (amyloid) referring to this starch-like 
reaction; the waxy substance, however, is a proteid, and reaches 
the liver by the hepatic artery, whence it is first deposited in the middle 
zone of the lobule, and later infiltrates the central and peripheral 
zones. It is essentially an infiltration, affecting primarily the capil- 
laries of the hepatic artery. Slight lesions may necessitate the use of 
the microscope for detection. Amyloid liver may co-exist with gumma, 
cancer, or cirrhosis. 

Symptoms. — The large, tense, symmetrical, painless, smooth liver, 
with rounded edges, is characteristic. Its measurements may attain 
those caused by cancer. The onset and development are usually 
slow, but acute amyloid has developed within a month. Splenic 
amyloid enlargement is usually also noted, as well as albuminuria 
from renal amyloidosis (q. v.). In only 0.8 per cent, of amyloid degener- 
ation is the liver alone involved (Fehr). Gastro-intestinal symptoms, 
as nausea, vomiting and diarrhoea may result from amyloidosis of 
the alimentary capillaries. In advanced cases cachexia, osdema and 
ascites may develop. Hepatargia is rare. 

Diagnosis. — Diagnosis depends on (a) the recognition of a cause; 
(b) the characteristic, smooth, symmetrical enlargement, which is less 
hard than that of cirrhosis; (c) the association with amyloid disease 
of the spleen, kidney, and alimentary tract; (d) the absence of icterus 
(which very rarely results from amyloid portal glands) and of portal 
stasis (ascites is infrequent, is a late symptom and results from renal 
implication) ; and (e) the small amount of urobilin in the stools. 
Differentiation from cirrhosis (q.v.) and cancer (q.v.) presents no 
difficulties. Gummata in the liver plus amyloid disease may cause 
confusion. No diagnosis is possible in the exceptional cases in which 
the liver is slightly enlarged, because it is only slightly diseased, or 
in those cases in which splenic tumor and albuminuria are absent. 
Other diffuse and focal hepatic diseases are differentiated in the table 
on page 724. 



ANOMALIES OF FORM AND LOCATION OF THE LIVER 719 

The prognosis of pronounced cases is unfavorable, though light 
grades may exceptionally regress (Budd, Bamberger, Frerichs, Graves). 

Treatment is unavailing; it is solely that of the causal condition 
and of the symptoms as they arise. 



(I). ANOMALIES OF FORM AND LOCATION OF THE LIVER. 

In situs viscerum inversus the liver lies on the left side, which in 
pathological conditions may lead to serious diagnostic error. Fenger 
and Billings mention a case of icterus and gall-stones in situs inversus 
which was diagnosticated as acute yellow atrophy! 

Tilting of the liver (ante- and retroversion), dislocation downward 
by pleuritis, pneumothorax or tumors, or upward luxation require but 
passing mention. 

The liver may be found in the thoracic cavity as a result of con- 
genital malformation or severe trauma. 

"Wandering liver" (hepar migrans s. mobile) occurs in women, 
(•in 88 per cent.) and usually after several pregnancies. Its causes are 
those of enteroptosis, with which it usually occurs, viz., flaccid abdom- 
inal walls, possibly congenital laxness of the suspensory ligaments, 
tight lacing, or very rarely from traction, as by a tumor. J. Dutton 
Steele collected 100 cases, which Clark and Dolley (1905) increased 
to 118; they report one case with a mesohepar attached to the dia- 
phragm and with absence of the coronary and right lateral ligaments. 

Symptoms. — Symptoms may be entirely lacking. In 5 per cent, 
the onset is acute (Graham), though usually gradual. Subjectively, 
vague pain or oppression over the liver, gastro-intestinal disorders 
or nervous symptoms may be present. Objectively, the liver is lower 
and is more mobile than normal; there is sometimes cardioptosis 
(Einhorn), usually gastroptosis, and in 20 per cent, nephroptosis 
(J. D. Steele). Its notch can be distinctly felt, often also its con- 
vex surface and sometimes the tense, stretched ligaments. It can 
be replaced. The entire liver, in extreme instances, may be below 
the costal arch, and tympany, due to the bowel, may exist between 
it and the lung. In a recent case seen with Dr. DeLee there was 
tympany between the left costal arch and the prolapsed spleen, and 
tympany between the right arch and the liver, even though the patient 
was five months pregnant. In very rare instances there may be pain 
similar to that of gall-stones; ascites, or splenic tumor, result from 
torsion of the portal vein. 

Treatment. — The treatment is (a) mechanical, which consists of 
replacing and supporting the liver with appropriate binders or pads; 
(b) symptomatic, with due consideration of the neurasthenic manifes- 
tations; (c) dietetic, in order to increase the body-weight and (d) 
operative, in which the liver is sewed to the diaphragm or abdominal 
wall. In 39 cases, hepatopexy cured about 75 per cent. 



720 DISEASES OF THE LIVER 

The corset liver is found in 25 per cent, of female cadavers (Leube), 
though it is much less frequent in the United States than in foreign 
countries. Corsets cause pressure-atrophy of the liver substance, 
which is followed by induration, peritoneal thickening and deformity; 
these changes are most conspicuous and usual in the right lobe. The 
liver may be merely constricted, or dislocated upward; or the part 
below the constricting zone may hang loosely as upon a hinge; this 
may cause diagnostic confusion with floating kidney, enlarged gall- 
bladder or other tumors. The gall-bladder is said to be dilated in 
60 per cent, of cases, though icterus is quite infrequent. Subjective 
manifestations are often absent, though there may be a sense of pres- 
sure over the part. Sometimes paroxysmal syncope and vomiting 
may occur; they are due to congestion of the snared-off portion of the 
liver. Physical examination often determines the condition, especially 
when, by careful palpation, the hinged and hard part can be proven 
directly continuous with the liver's known margins. Respiratory 
excursion is naturally imparted to it in most cases. Confusion neces- 
sarily arises when a loop of gut causes a small zone of tympany be- 
tween the hinged segment and the liver proper, but even then careful 
palpation frequently demonstrates its continuity with the liver. Con- 
genital tongue-like lobes may be confused clinically with corset liver; 
they are often cirrhotic and relatively often the seat of malignancy, 
suppuration or syphilis. Corset liver is regarded as a disposing factor 
in gall-stone formation. Treatment is seldom possible nor is it im- 
portant, though prophylaxis and perhaps resection should be men- 
tioned. 



(J). AFFECTIONS OF THE BLOODVESSELS OF THE LIVER. 

I. Active Hyperemia of the Liver. 

A degree of arterial hyperemia is physiological during digestion, 
when an excess of blood is found in the portal circulation. An accen- 
tuation of this condition is common in heavy eaters and drinkers, in 
trauma and acute infections, in the latter of which it may be combined 
with venous hyperemia. Heat is probably not a cause, though some 
physicians in the tropics speak of tropical hyperemia. The alleged 
vicarious hyperemia from suppressed menstruation, the menopause, 
or diseases of the internal female genitalia, is based wholly on theory. 
The symptoms resemble those of passive hyperemia (v.i.), viz., some 
hepatic enlargement, moderate discomfort in the right hypochondrium, 
and also, it is alleged, slight icterus. Treatment is seldom indicated, 
save in cases of dietetic excesses, where gastro-intestinal symptoms 
also obtain. Then a simple, moderate, or milk diet, together with 
calomel and saline purgation, is indicated. 



PASSIVE HYPEREMIA OF THE LIVER 721 



II. Passive Hyperemia of the Liver. 

Etiology. — Passive congestion of the liver results from various 
kinds of stasis, the stress in all of which is felt in the efferent hepatic 
(sublobular) veins within the liver. It results (a) from cardiac insuffi- 
ciency, which is caused by valvular diseases, particularly mitral, myo- 
cardial maladies or pericardial lesions (effusion or synechia;) (b) from 
pulmonary stasis, due to emphysema, chronic bronchitis, asthma, 
induration or obliterative pleurisy; (c) from stasis caused by spinal 
deformity, aneurysm, mediastinal tumor, perihepatitis, or pressure on 
the cava inferior. 

Pathology. — The essence of passive congestion is over-filling of the 
sublobular or the hepatic venous circulation, malnutrition of the liver 
cells {fatty degeneration) and in some advanced cases, increased con- 
nective tissue. The liver is usually symmetrically enlarged, firmer, and 
a darker red than normal, though hepatic hyperemia lessens after 
death. The capsule is often thickened or cedematous. On section 
the so-called nutmeg appearance is noted, but this seldom occurs 
over the entire liver. The central veins with their radiating offsets 
are dark, cyanotic, and sometimes sclerotic from stasis, while the 
periphery of the lobule is yellow-white from cloudy or fatty change 
(malnutrition or impaired oxygenation). The nutmeg appearance is 
not pathognomonic of passive congestion. Long-standing congestion 
results in atrophy and pigmentation of the cells in the periphery of the 
lobule ( Virchow's red atrophy); there is usually increased connective 
tissue with fine granulations; this is the atrophic cyanotic liver or the 
cardiac cirrhosis of the French; fibrosis is probably for the most part 
relative or apparent, for the liver parenchyma atrophies; true cir- 
rhosis may co-exist with cardiac disease. 

Symptoms and Diagnosis. — (a) The causal heart (or lung) lesion 
has its appropriate symptoms. (6) The liver is evenly enlarged, both 
on percussion and palpation, sometimes also on inspection; if ascites 
is present, thrusting palpation with the finger-tips usually outlines the 
organ; the liver may reach to the navel or even lower and may evert 
the ribs. Its edges are firmer than normal, somewhat rounded, sen- 
sitive (frOm capsular tension) and descend with inspiration; the incisure 
is clearly felt. If there is relative tricuspid insufficiency, a systolic 
expansile pulsation is detected by palpating with both hands, which 
are separated from each other with each systole. This is readily 
differentiated from the non-expansile pulsation which is transmitted 
to the liver from the aorta, (c) The hepatic intumescence varies 
greatly, as the heart responds to rest or to digitalis, or fails in com- 
pensation, (d) The skin shows cyanosis and is also tinged with slight 
icterus; to the experienced eye, it has a characteristic appearance, 
which is probably due to a static catarrh of the finer interhepatic 
bile radicles, (e) For other symptoms, see Signs of Stasis under 
Valvular Disease. The spleen is seldom enlarged save from cardiac 

46 



722 DISEASES OF THE LIVER 

infarcts or complicating liver cirrhosis. Heematemesis is infrequent. 
Albuminuria and gastro-intestinal symptoms are referable to the heart. 
Ascites is usually late in appearing and moderate in degree; the earlier 
statement, that an ascites, which is disproportionately marked in 
comparison with the general oedema, indicates the atrophic (indurated) 
nutmeg liver, is incorrect, because a cardiac ascites sometimes oc- 
curs without general cedema. Toward the end of the course there 
may be signs of renal and hepatic insufficiency. 

Differentiation is seldom complicated, for the fundamental heart 
lesion, the evenly enlarged, tender liver, which varies in size from 
time to time, and the slight icterus with the cyanosis, are usually un- 
mistakable. Certain features may sometimes mislead, as the occasional 
unequal distribution of the liver changes, which may suggest tumor; 
the tenderness in two cases which the author saw was thought to be 
suppurative. (See table page 724.) The treatment is that of uncom- 
pensated valvular disease (q. v.). 

III. Pylethrombosis — Pylephlebitis. 

Thrombosis or phlebitis of the portal vein is practically always 
secondary to compression or obstruction, as liver cirrhosis with which 
33 per cent, of pylephlebitis cases occur; to cancer, ulceration, abscess 
or inflammation of contiguous structures, gall-stones, cholangitis and 
chronic proliferative peritonitis; and to diseases of the intima, as 
phlebosclerosis and syphilitic endophlebitis; all cases are promoted 
by slowing of the portal current. Parasites (distoma and bilharzia 
haematobium) and embolism are rare causes (embolism rarely causes 
complete liver necrosis unless the hepatic arteries are simultaneously 
closed). Pylephlebitis and thrombosis occur chiefly in males over 
forty years of age. 

A fatal obliterating endophlebitis exists with symptoms very closely 
resembling those of atrophic cirrhosis; Hess in 1905 collected 23 cases 
from the literature. 

Symptoms. — These may be entirely absent because of collateral 
compensation through the hepatic artery or Sappey's accessory portal 
vein. The onset is usually sudden, with symptoms of acute portal 
stasis. The spleen is enlarged in 75 per cent., unless fibrous changes in 
its pulp or capsule prevent its swelling. Ascites develops in 66 per cent, 
and rapidly recurs after tapping. Gastro-intestinal symptoms are usual, 
as hemorrhage (44 per cent.), intense sudden epigastric pain, vomiting, 
diarrhoea or sometimes acute intestinal obstruction. The portal vein 
is sometimes varicose below, and is generally obliterated (pylephlebitis 
adhsesiva) at and above the point of obstruction; this leads to shrink- 
ing of the liver, particularly if the hepatic artery is sclerotic, in which 
case the entire liver may rarely be hemorrhagically infarcted. The 
liver is said to become lobulated, but this probably results from ante- 
cedent syphilis. Symptoms of hepatargia (hepatic insufficiency or 
toxaemia) may develop. Alimentary glycosuria is fairly frequent. 



AFFECTIONS OF THE HEPATIC ARTERY AND VEIN 723 

(Edema of the abdominal wall, development of a collateral circulation, 
and icterus are uncommon. 

Diagnosis. — Diagnosis is difficult, unless the onset is typically sud- 
den, in which case pylethrombosis may be considered. Save for 
their acuity, the findings are those of atrophic cirrhosis; a caput 
Medusas rather indicates occlusion of the portal radicles than of the 
portal trunk. The ascites may suggest carcinoma or peritonitis, or 
the hemorrhage may simulate gastric ulcer or hepatic cirrhosis. 

Course and Treatment. — Death may occur in a few days or the 
patient may live for months or years (six to twenty years). Treatment 
is ineffectual, save in early syphilitic cases. Citric acid (5j) may be 
given every few hours, in an attempt to lessen thrombosis. Talma's 
operation may be considered. 

Pylephlebitis suppurativa has been considered under liver abscess. 
It is a pyaemia of the portal vein; metastasis or extension occurs in 
the main portal trunk and its branches from infection of its radicles 
of origin; ulcerations and inflammations in the gastro-intestinal tract 
are its cause in 75 per cent, of cases; appendicitis causes about 40 
percent. (Dieulafoy's " appendicular liver") and gall-stones, infected 
piles, and pancreatic or umbilical suppuration cause most of the 
other cases (v.s. Liver Abscess, Second Variety). 

The symptoms are those of the original disease, those of sepsis and 
those of portal stasis. In very rare cases the thickened vein may be 
palpated. The spleen is enlarged, chiefly from sepsis, though sometimes 
from stasis. The liver is tender and somewhat enlarged, icterus occurs 
in over 50 per cent., and the usual signs of sepsis prevail. The diag- 
nosis is always difficult, but is based on symptoms suggesting liver 
abscess (though without the findings of solitary abscess) on the one 
hand and those of sepsis on the other. The treatment is practically 
futile, being supportive and rarely, if ever, operative. 



IV. Affections of the Hepatic Artery and Vein. 

These are of more pathological than clinical interest. Infarction 
of the hepatic artery with complete necrosis of the liver is very 
rare. 

Aneurysm (q.v.) can seldom be diagnosticated. Pulsation is un- 
known; pain is nearly always present, icterus and a tumor occur in 
the majority of cases, ascites is uncommon and death usually results 
from gastro-intestinal hemorrhage. 

Thrombosis of the hepatic veins is very infrequent, only 12 cases 
being reported. It may follow perihepatitis, or, less often, compres- 
sion by a neoplasm, or fibrous obliteration of the inferior cava. Ascites 
and splenic tumor sometimes result. Suppurative thrombosis is always 
secondary to liver suppuration. Retrograde embolism (Heller) is 
mentioned under liver abscess. 

Syphilis of the Liver (see Syphilis). 



724 



DISEASES OF THE LIVER 













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ICTEROVS 725 



DISEASES OF THE GALL-BLADDEB AND BILE 

VESSELS. 

(A). ICTERUS. 

Icterus or jaundice is a symptom of various affections of the liver 
and bile vessels; it usually results from obstruction to the bile flow, 
and is characterized by staining of the skin, mucosae, and urine by 
retained bile pigments. 

Etiology. — Most cases of icterus are due to obstruction either within 
or about the liver and biliary system; but slight obstruction is neces- 
sary because the bile is secreted under very low pressure, (a) It 
may result from hepatic diseases. It is (i) frequent in carcinoma, 
biliary cirrhosis, atrophic cirrhosis, multilocular echinococcus and 
passive congestion ; (ii) infrequent in unilocular echinococcus, abscess, 
and syphilis; (iii) absent in fatty and amyloid liver and in simple 
pylephlebitis. Pick, Liebermeister, and Minkowsky believe that 
occasionally functional liver disturbance may produce icterus (para- 
pedesis of bile, "diffusion-icterus" or paracholia) which is analogous 
to transient albuminuria (in its relation to B right's disease), (b) Dis- 
eases of the biliary tract may be etiological factors, as (i) catarrhal, 
croupous, or purulent inflammation; (ii) calculous obstruction; (iii) 
congenital and (iv) cicatricial occlusion; (v) malignant growths; (vi) 
parasitic obstruction by ascaris, distoma, or hydatid vesicles, (c) It 
may result from disease in contiguous structures, as (i) duodenal 
ulcer, cicatrix, catarrh, or malignancy; (ii) tumors of the colon or 
lymph glands; (iii) tumors or inflammation of the pancreas, stomach, 
kidney, omentum, mesentery, and peritoneum, and (iv) rarely from 
visceroptosis, or aneurysm, (d) The so-called hematogenous or uro- 
bilin icterus is a possible factor in the etiology. It was formerly main- 
tained that toxic and toxsemic conditions break down the blood cells 
(haemolysis), and thus cause icterus (the cytohsemolytic icterus of 
Senator). It is now thought that most of these cases are essentially 
obstructive (thickening of the bile or cholangitis of the smallest rad- 
icles), though the obstruction of the small bile ducts within the liver 
is not complete. From a recent work by Eppinger, it appears that 
the smaller bile radicles dilate and sometimes rupture, letting the 
bile into the lymph vessels which absorb it; he thinks the mechanical 
obstruction lies in the capillaries which were blocked by fibrin or bile 
thrombi. The jaundice in these cases is slight, bile pigment (bilirubin) 
is not found in the urine, and the stools are bile-stained. This type 
occurs (i) in various infections, relapsing fever, septicopyemia, etc., 
(ii) in pernicious anaemia, and (iii) in toxic conditions, poisoning by 
phosphorus, chloroform, felix mas, and santonin. 

Icterus neonatorum may be considered here, (a) The physiological 
type occurs in 30 per cent, (to 80 per cent.) of children; it appears 



726 DISEASES OF THE GALL-BLADDER 

on the second day, lasts two weeks and is never fatal; its cause is 
not clear, though breaking down of the blood, increased blood pres- 
sure within the liver and persisting patency of the ductus venosus 
are suggested, (b) The much rarer pathological type may be caused 
by sepsis, syphilis, WinkeFs disease or still more exceptionally by 
congenital obstruction, gall-stones (10 cases collected by Skormin), 
acute yellow atrophy (7 cases) or catarrhal icterus (but 3 cases 
recorded). Glaister reported a family in which 6 cases of jaundice 
developed after birth. Krannhals recently published 26 cases of con- 
genital "family icterus" most of which had an enlarged spleen. 

Symptoms of Icterus. — Bilirubin, found normally in the bile, enters 
the blood in biliary obstruction, by the lymph vessels and possibly 
also by the bloodvessels, and produces the following symptoms: 

1. Staining of the skin and mucosas occurs in two or three days. 
The sclera?, skin and accessible mucosae are yellow, and, in cases of 
long standing, dark brown. The skin itches because of its dryness, 
or because of the action of the bile on the nerves. Eruptions of urti- 
caria or xanthoma may occur. 

2. The urine contains bilirubin before icterus is seen in the skin. 
Adding nitroso-nitric acid to the urine in a porcelain dish or on filter 
paper gives the characteristic play of colors, of green, yellow, violet and 
red (Gmelin test). If the urine is agitated, the yellow color appears in 
its foam. Confusion is possible with melanuria, hsematuria, urobili- 
nuria or staining of the urine with rhubarb, picric acid, santonin, senna 
and chryosophanic acid. The subject of urobilinuria and urobilin- 
icterus has caused much discussion ; urobilin is formed in the intestine 
by the reduction of bilirubin, whence it is absorbed and excreted by 
the urine; it never stains the skin, and icterus results from bilirubin 
alone. To reconcile the apparent inconsistencies in the urinary findings 
and in various statements, it may be said that there are three classes 
of cases; (a) in complete biliary obstruction with icterus, only bili- 
rubin is found in the urine, for none of it reaches the intestine to be 
converted into urobilin; (b) in partial obstruction, bilirubin is found 
in the blood and urine and also some urobilin, which is produced in 
the intestine from the bilirubin, for there is much intestinal fermen- 
tation; (c) in slight obstruction, there is no bilirubin but much uro- 
bilin in the urine. Albuminuria may occur or cylindruria alone, and 
the hyaline casts or desquamated epithelium are then bile-stained. 
The sulphates, which normally constitute 14 to 25 per cent, of all the 
sulphur output, may be increased to over 40 per cent. Indicanuria 
is often marked and is due, like the sulphate increase, to greater intes- 
tinal putrefaction. 

3. The digestive tract suffers from the exclusion of bile. The tongue 
is coated, the breath has a disagreeable odor and the mouth may have 
a bitter taste, which is due to toxaemia. There may be an especial 
aversion to fats and sometimes to proteids, and there may be nausea. 
The abdomen is distended, which is thought to be due to the absence 
of the antiseptic action of the bile, though the importance of this 



ICTERUS 727 

action has been overestimated. Starchy food is not wholly absorbed, 
albumin digestion is somewhat impaired and fat is found in large 
amounts in the stools (steatorrhea). The function of the pancreas 
in this respect is far more important than that of the bile. Vegetables 
are absorbed better than animal fats. The normal amount of fat 
found in the fseces is 7 to 10 per cent., and this is increased in icterus 
to 55 or 78 per cent. The stools are clay-colored, constipated and stink- 
ing; they may shimmer when the fatty soap crystals are abundant; 
they are also dry (the bile in the fseces amounts normally to nearly a 
quart a day). If the obstruction is incomplete — as in many intra- 
hepatic diseases — the stools are merely somewhat lighter than normal ; 
a nitrogenous diet may impart a brownish color to the fseces. The 
fseces may appear deceptively dark if voided with the urine which 
lends a yellow color to their surface. 

4. Cholamia (hepatargia or hepatic insufficiency) may finally result. 
It was once thought to be due to the cholestearin, or bile salts, but 
more probably results from injury to the liver cells which then fail 
to destroy the usual intestinal toxins and those formed in excess by 
the increased putrefaction. Its symptoms rather resemble those of 
acute yellow atrophy, i. e. nervous excitation followed by sopor, irregular 
breathing, or cutaneous and other hemorrhages. Most subjects of 
icterus are depressed, irritable, sleepless and somewhat emaciated. 
The hemorrhages are thought by Mayo Robson to result from coin- 
cident pancreatic involvement (diminished lime salts or the glycerine 
which is formed by fat necrosis of the pancreas). 

5. There may be other symptoms, (a) The heart rate is slow, par- 
ticularly in catarrhal forms or recent cases and in the absence of pain, 
fever, and intoxication; it may go as low as~21 (Frerichs); it has been 
said that this is due to degeneration of the heart muscle or action of 
the bile-salts on the intracardiac ganglia, but it is probably caused 
by vagus stimulation, for atropine will raise the rate (Weintraud). 
The arterial pressure is low and the capillaries wide. A functional 
heart murmur may develop; this is usually caused by myocardial 
weakness. Potain holds that the lung capillaries contract reflexly, 
thereby increasing the work of the right heart and causing its dilata- 
tion. The respiration rate is decreased, even to 7 or 9 a minute; the 
temperature is usually normal. (6) The blood shows the bile stain, 
and in severe cases delayed coagulation, ansemia, and leukocytosis. 
The undiluted or diluted blood may give a partial Widal reaction 
(see Typhoid), (c) The liver cells may suffer mechanically and chem- 
ically from bile stasis, and may be smaller, altered in form, pigmented, 
necrotic and bile-stained. The gross and minute anatomy varies with 
the cause. The bile vessels are often dilated, sometimes thickened, 
and occasionally ruptured. The condition of the gall-bladder will be 
discussed under gall-stones and pancreatic cancer. As stated under 
biliary cirrhosis, it is questionable whether simple biliary stasis ever 
causes induration of the liver, (d) The spleen is occasionally enlarged, 
especially in children, from infection or portal stasis, but splenic tumor 



728 DISEASES OF THE GALL-BLADDER 

is no part per se of bile stasis, (e) The tissues most stained are the 
skin, mucosae, fasciae, intima and connective tissues; the fluids most 
stained are the urine, serous transudates and purulent exudations. 
The milk, sweat (the foetus, in pregnant women), and pneumonic 
sputum are sometimes stained, and the tears, saliva, mucus, glandular 
and epithelial structures (except the renal cells and lowest layers of 
the rete Malpighii), muscles and nervous tissues (except in the more 
severe type of icterus neonatorum) are seldom icteric. (/) Xanthopsia, 
yellow coloring of objects seen, is fairly common, and is due to the 
action of bile pigment on the nervous tissues. The explanation of 
nyctalopia and hemeralopia is uncertain, (g) Xanthelasma multiplex 
develops in some cases. Twenty-three cases were collected by the 
London Pathological Society in 1882. Futcher in 1905 reported three 
cases in women about forty years of age; 80 per cent, of reported 
cases of xanthelasma occur in chronic icterus (in women more fre- 
quently than in men), due to gall-stones, stricture of the bile-ducts, 
cirrhosis, hydatids, and cancer. They are often symmetrical, often 
begin on the eyelids or the folds and creases of the skin, in one case 
were found in the bile ducts, rarely disappear and are probably due 
to some toxic substance, though Williams believes they are epithelial 
in origin. Some few cases begin before puberty and are probably 
hereditary. 

Diagnosis. — A diagnosis is easily made. Icterus may not be noticed 
in artificial light, for daylight is absolutely essential for its certain 
detection. It is seldom confused with anaemia, cachexia, Addison's 
disease or the pigmentation of vagabondism. Pingueculae are 
often mistaken for scleral staining, but only on superficial examin- 
ation. 

The prognosis and treatment cannot be considered, as icterus is but 
a symptom. The details depend on the basic affection. (See Catar- 
rhal Jaundice for treatment in general.) The patient may recover 
after four years (Budd) ; cases of icterus lasting six years (Murchison, 
Barth, Bosnier), ten to twenty-five years (Legendre, Galliard) or even 
fifty-two years (Masing) have been reported. 



(B). CHOLELITHIASIS. 

Gall-stones are found in 6 to 10 per cent, of autopsies. Among the 
many literary contributions to this subject are those of Naunyn, 
Langenbuch, Kehr, Riedel, Lange, Mayo Robson, Keen, Fenger, 
Murphy and Mayo. 

Etiology. — 1. Immediate Cause. — The actual cause is catarrhal 
inflammation of the gall-bladder or bile vessels, which promotes the 
formation of (or actually secretes) cholestearin and lime. Stagnation 
of bile is merely a predisposing cause. Bacteria play an important 
role, especially the typhoid (found in 33 per cent.) and colon bacilli; 
they have been found in calculi, and cholelithiasis has been experi- 



CHOLELITHIASIS 729 

mentally produced by their inoculation; the Bacillus typhosus may 
live seven years in the gall-bladder. 

2. Predisposing Factors. — (a) Age; 50 per cent, of cases occur in 
persons over forty years of age; the affection is rare in those under 
twenty years but has been seen in the young and even in the new-born. 
(b) Sex; 70 to 80 per cent, occur in women, in whom pregnancy, 
menopause, lax abdominal walls, enteroptosis, and constipation, seden- 
tary life, and lacing, are regarded as promoting factors; Bollinger and 
Bother found that 40 per cent, of women, who have gall-stones, also 
have the corset liver. According to Naunyn, gall-stones are found in 
25 per cent, of autopsies on women over sixty years; 90 per cent, of 
women affected have borne children, (c) Other possible factors are 
sedentary habits, obesity, splanchnoptosis, luxurious living, insanity, 
cancer of the stomach, biliary stasis, and foreign bodies in the biliary 
tract; Kehr holds that stone-formation is induced by long intervals 
between meals. Cholelithiasis is more common in cool than in warm 
climates. 

Properties of Gall-stones. — (a) Site; they are almost invariably 
formed in the gall-bladder; very rarely do calculi develop in the intra- 
hepatic ducts as reported in Mc Arthur's recent case. (b) Size; they 
range from the size of sand or gravel to that of an egg; sl calculus 
12 inches in length is recorded; the heaviest weight reported is over 
four ounces (135 gm. Ritter). (c) Form; they are usually round 
and rarely spinous; when multiple they are polygonal and facetted. 
Intrahepatic calculi may be cylindrical or branching like coral 
(Cruveilhier). (d) Their number probably averages a dozen; ac- 
cording to Riedel 44 per cent, are single; Naunyn reports 5,000 
in one case, and Otto 7,802 stones in another case. Chopart 
instances a case in which the liver could scarcely be cut because 
of the numberless stones in the intrahepatic ducts, (e) Consistence; 
gall-stones can usually be indented by the finger. (/) The time 
required for their growth is about six months, (g) Chemistry; the 
most common form consists of cholestearin and bile-figment (bil- 
irubin and biliverdin) with some lime as a cementing substance; 
these calculi are small, numerous, usually yellow, laminated and con- 
tain about 75 per cent, of cholestearin. Cholestearin stones are not 
common; they are translucent, become opaque when dry, are light 
in weight and color, and are combustible; they present a crystalline 
fracture like that of camphor, they dissolve in ether and alcohol, 
from which the crystals are precipitated and produce a red tinge on 
addition of chloroform and sulphuric acid; cholestearin comes not 
from the bile but from the inflamed mucosa of the gall-bladder. 
Pigmentary stones are also uncommon; bilirubin imparts a brownish 
and biliverdin a greenish tint to them. Calcium carbonate stones are 
rare, are grayish in color and heavy. Stones in the liver are con- 
stituted of calcium and bilirubin as in Lewis L. McArthur's recent 
case. Traces of magnesium, bile acids, fatty acids, iron, and copper 
have been found. The nucleus may consist of mucin, bacteria, epi- 



730 DISEASES OF THE GALL-BLADDER 

thelium, blood-clot, cholestearin, calcium, bile pigment or rarely of 
foreign bodies. 

Symptoms. — Kehr, Riedel and Paulsen assert that 96 per cent, 
of cases of gall-stones have no symptoms, especially in elderly subjects 
with atrophic gall-bladders. Naunyn states that gall-stones are found 
at autopsy in 25 per cent, of women over sixty years of age. Stones 
may be felt or may crepitate in the gall-bladder, or be found in the 
faeces, especially in old people with lax tissues, without any subjective 
symptoms. 

An attack of biliary colic embraces several important elements, (a) 
Colic is usually sudden in onset and very frequently begins at night. 
The pain is great, and many women state that it is more severe than 
labor pains. It begins in the right upper abdominal quadrant and 
may radiate to the back, navel, hypogastrium, left side, and even to 
the arms, legs, testes, or chest. Irregular or large stones cause the 
greatest agony which is controlled only by large or repeated hypodermics 
of morphine. The pain usually endures for minutes to a few hours, 
and may soon recur. According to Riedel colic is absent in 20 per cent, 
of cases, which implies that the stones are small or the tissues are lax. 
The cause of biliary colic is mechanical, — the attempt of the stone 
to migrate produces the spasm of the cystic and common ducts during 
its passage but some consider that inflammation is the chief factor; 
Kehr maintains that cholecystitis starts the stones moving by the 
exudation it induces. The author has seen violent colic result from 
this mechanism as well as from cholecystitis without stones. It is 
thought that quiescent gall-stones may be started onward by palpation 
of the gall-bladder, trauma, muscular exertion, pressure by corsets, 
particularly after reduction of flesh, menstruation, or delivery, (b) 
Reflex nausea and vomiting are frequent; Kehr thinks that they 
indicate cholecystitis (Mierzkowski found the bile sterile in only 22 
per cent.). Vomiting relieves the pain, and this frequently causes an 
erroneous diagnosis of gastralgia. Torsion of the cystic duct may 
cause vomiting but not colic, (c) Chills and fever occur in 60 per cent, 
and probably indicate bacterial inflammation (though they are possibly 
reflex) . id) The gall-bladder i s always tender, there being hyperesthesia 
over the ninth costal cartilage or over a point two-thirds of the distance 
between it and the navel. In 33 per cent, of cases the gall-bladder is 
palpable. The right rectus muscle is rigid. Boas and Gruh describe 
a right-sided hypersesthetic zone which lies between the spine and 
posterior axillary line and at the level of the lower dorsal or upper 
lumbar vertebra, (e) Icterus, which is so often emphasized as a 
diagnostic point, is present in but 10 to 20 per cent. (Riedel and Kehr), 
and in but 14 per cent, of Murphy's series. It may be mechanical or 
inflammatory; Deaver is inclined to refer it to inflammation in the 
pancreas (v. i.). (/) Other symptoms of the paroxysm are rapid pulse, 
sweating, prostration, concentrated urine, constipation, abdominal 
retraction and, after the seizure, marked prostration. In some cases 
convulsions or other hysterical manifestations may be precipitated. 



CHOLELITHIASIS 731 

Attacks of migraine are not infrequent (Kehr). There may be reflex 
coughing or reflex contraction of the pulmonary capillaries, which puts 
extra work on the right heart and causes its dilatation. The patient 
may suffer actual collapse, and in nine cases death has occurred in the 
attack (Naunyn). Glycosuria, albuminuria, leukocytosis, and splenic 
swelling are probably inflammatory in origin. The stone may fall 
back into the gall-bladder or pass into the bowel if it measures not 
more than 1 cm. It is detected by washing of the stools through a 
cloth; confusion with lumps of olive oil, which may have been given 
to relieve the colic, is unnecessary. The passage of a round calculus 
suggests, but does not prove, that it is the only one. Stones passing 
into the bowel may be dissolved, unless coated with cholestearin ; 
this may explain why stones are not more often found in the faeces. 
The great importance of gall-stones lies in their complications. 

Complications. — Complications may be grouped as mechanical or 
inflammatory but as this involves descriptive repetition, both forms 
may be combined topographically. Such complications as liver abscess 
or pyaemia may develop from stones which were without any clinical 
symptoms. 

1. Gall-bladder. — Mechanical complications include pressure on the 
duodenum or pylorus and rupture of the gall-bladder, which, however, 
are generally inflammatory; pressure on the common duct; hyper- 
chlorhydria and hypersecretion; and cancer of the gall-bladder (q.v.). 
Inflammatory complications are more serious; all forms and sequences 
of cholecystitis (q.v.) may develop, as hydrops, empyema, gangrene, 
ulceration, deformity, hemorrhage, atrophy, calcification or liver 
abscess; also pylephlebitis, adhesions producing pyloric obstruction 
with hyperchlorhydria, dyspepsia, and sometimes hemorrhage into the 
stomach; adhesions causing duodenal obstruction; and peritonitis, 
either local (near the gall-bladder, or subphrenic abscess) or diffuse; 
Courvoisier reported 49 cases of the localized and 70 of the diffuse 
type. A friction rub may be heard over the gall-bladder a day or two 
after the colic. The distended gall-bladder rarely exceeds the size of 
the fist, is pyriform, can be moved laterally and moves with the liver, 
from which it may seem to be separated by a groove; it may be some- 
times confused with appendicitis, the kidney, ovarian cyst or ascites, 
and has even been found in a femoral hernia. 

2. Cystic Duct. — Mechanical impaction may cause icterus by induc- 
ing spasm or catarrh of the common duct (in 10 to 15 per cent., Riedel) 
or by directly compressing it. The duct may become twisted, stenosed, 
or obliterated. 

3. Common Bile Duct. — Its mechanical occlusion is usually but 
not invariably preceded by colic, and impaction occurs oftenest at 
its lower end (50 per cent. Courvoisier, or 67 per cent. Robson), is 
caused most frequently by one stone, though as many as 88 have been 
found (Mayo Robson). Permanent occlusion by stone in the common 
duct, or in the cystic duct pressing upon it, causes marked icterus, 
usually without sepsis. The occlusion may be partial or intermittent, 



732 DISEASES OF THE GALL-BLAaDER 

by a ball-valve action of the stone, described by Osier and Fenger, 
which allows some bile to enter the gut and, unfortunately, some 
bacteria to enter the duct, thus adding bacterial to mechanical injury. 
In isolated cases there is no icterus but usually the icterus is sudden in 
onset and slow in subsidence. In partial or intermittent obstruction 
there is often the intermittent hepatic fever, which was first described 
by Charcot and later clearly defined by Osier. Budd well compared it 
to urethral fever. During the paroxysms the fever rises to 103 or 105°, 
often with chills, sweats, leukocytosis, vomiting, and increased tender- 
ness, pain, and icterus. The spleen may swell as well as the liver, 
from cylindrical or saccular dilatation of the bile channels and from 
cholangitis. Osier has correctly insisted that this group of symptoms 
occurs without suppurative cholangitis, though of course with infection. 
The gall-bladder is not enlarged, but is usually shrunken, following 
Courvoisier's law; Courvoisier (1890) found the gall-bladder enlarged 
in 92 per cent, of 100 cases of non-calculous obstruction of the common 
duct, and shrunken in 80 per cent, of calculous obstruction (87 cases) ; 
this is caused by infection (Hanot); Eichlin in 139 cases of non- 
calculous obstruction, found the gall-bladder dilated in 87 per cent., 
and contracted or normal in 6.5 per cent, each; in 172 cases of cal- 
culous obstruction, the gall-bladder was contracted in 66 per cent., 
normal in 19 per cent, and dilated in 15 per cent. In some cases sup- 
purative cholangitis may complicate stones of the common duct with 
remittent fever (rather than the above described intermittent fever), 
enlarged liver, septic symptoms and more intense and more rapidly 
fatal course. Mechanical dilatation may distend all the bile-vessels 
and these may be seen under the capsule; ascending cholangitis may 
cause subcapsular abscess. Cicatricial stenosis of the common duct 
is rare; pylephlebitis may develop. Malaria is excluded by examina- 
tion of the blood; malignancy will be considered under tumors of the 
pancreas, though in obstruction of the common duct, the nutrition is 
generally but little impaired. Practically, special stress may be 
placed on (a) the periodic fever, (b) the icterus sudden in onset and 
subsiding slowly, and (c) tenderness (without pain over the liver). 

4. Ampulla of Vater. — Calculous retention in the ampulla may 
obstruct the flow of the pancreatic juice, though the accessory duct 
may carry it into the intestine; retention may allow bile to enter the 
pancreatic duct, and result (a) in acute pancreatitis, caused by bile 
in the pancreatic ducts (Opie); (b) in chronic induration of the head 
of the pancreas, resembling malignancy (Riedel, Robson, Barling); 
(c) in pancreatic fibrosis with pancreatic calculi due to stasis and infec- 
tion; or (d) rarely in glycosuria. 

5. Intestinal Obstruction (q.v.). — Two hundred and fifty cases 
have been collected. The stone usually ulcerates its way into the 
bowel from the biliary channels or gall-bladder. The obstruction is 
often incomplete and may not occur for some time, sometimes receiv- 
ing new layers of magnesia or phosphates. According to Courvoisier, 
the obstruction is in the ileum in 66 per cent., duodenum in 21 per cent., 



CHOLELITHIASIS 733 

ileocecal valve in 10 per cent, and sigmoid in 3 per cent. About 50 
per cent, of cases die. 

6. Fistulae. — Naunyn assembled 384 cases. The external form con- 
stitutes about 50 per cent, of cases (Naunyn and Courvoisier) ; they 
are most often located near the navel, and about 40 per cent, of them 
heal. In the duodenal form (28 per cent.) the fistula is between the 
duodenum and gall-bladder and less often between the common duct 
and the gall-bladder. In 13 per cent, there is a fistulous opening into 
the colon. Courvoisier and Graham collected 34 cases of bronchial 
fistula. In rare cases, stones enter the stomach (five cases recorded, 
Snively, 1903), portal vein, hepatic artery, kidney, urinary bladder 
(200 gall-stones were evacuated in the urine in the case of Barraud- 
Palletan), pericardium, retroperitoneal tissue, vagina or even the 
pregnant uterus. 

7. Renal Calculus, Glycosuria, Etc. — In 700 cases of gall-stones, 
Kraus found the following complications: renal calculus in 6 per 
cent., glycosuria in 7 per cent., diabetes in 4 per cent., and gout in 2 
per cent. 

Diagnosis. — The diagnosis is easily made when colic, vomiting, 
tenderness of the gall-bladder and icterus are present, but icterus is 
absent in at least 80 per cent, of all cases. The arrays may produce 
no shadow in cholestearin calculi. 

1. The Colic. — This is most apt to be confused with (a) gastralgia, 
for both conditions are relieved by vomiting; due regard for other 
symptoms of gall-stones, and the habit of doubting every diagnosis 
of gastralgia, will save many mistakes, (b) A diagnosis of hepatic 
neuralgia should always be made with reserve, though pain near the 
liver does occur in neurotics, (c) Gastric or duodenal ulcer (q.v.), 
and (d) hyperchlorhydria and hypersecretion (q.v.) are easily dis- 
tinguished, (e) Lead colic has other characteristic symptoms, such 
as the gingival lead line, obstinate constipation, and often neuritic 
manifestations. (/) Tabetic crisis is attended by the Argyll-Robertson 
pupil, absent knee-jerk, and ataxia, (g) Renal colic (q.v.) is dis- 
tinguished by pain reflected down the ureter, hematuria, and pyuria, 
and DietTs crisis in floating kidney, by bimanual examination of the 
abdomen, (h) Mucous colic (colitis) is differentiated by the char- 
acteristic stools and neurasthenic symptoms, (i) Appendicitis is char- 
acterized by its four cardinal symptoms (q.v.); Ochsner finds 10 per 
cent, of his appendicitis cases complicated by gall-stones and 33 per 
cent, of his gall-stone cases by appendicitis, (j) Acute pancreatitis 
(q.v.) which may complicate gall-stones, causes greater collapse and 
more frequent intestinal obstruction, (k) Febrile syphilis may simu- 
late gall-stones (Riedel) as may also (I) the abdominal crises occasion- 
ally observed in angioneurotic oedema. 

2. Other Affections of the Gall-Bladder and Bile Ducts (see Brew- 
er's Table). 



734 



DISEASES OF THE GALL-BLADDER 



Beewee's Diagnosis of Diseases 



Pathological condition! Pain. 


Fever. 


Vomiting 


Jaundice. 


Tumor of gall- 
bladder. 


I. Calculous 








Disease. 










(a) Stone in healthy Xo. 


Xo. 


Xo. 


Xo. 


May be present 


gall-bladder, ducts 








from large num- 


free. 








ber or size of 
stones. 


(b) Stone in healthy May be absent; generally 


Xo. 


May be 


Xo. 


May be present 


gall-bladder, cystic present during obstruc- 




present 




from distention. 


duct temporarily tion; paroxysmal. 




when 






obstructed. 




colic 
occurs. 




(c) Stone impacted in Xo. 


Xo. 


Xo. 


Xo. Present; may 


cystic duct. 








attain large size. 



(d)iStone in hepatic Frequently present; irregu- 
duct. lar type. 



(e) Stone in common Present; acute paroxysmal 

duct; acute obstruc-i radiating to back. 

tion. 
(/)^Stone in common Periodic attacks of acute 

duct; movable; radiating pain. 

chronic. 

(g) Stone in common May be absent; frequently 
duct; impacted; t present early; may be 
chronic. intermittent; variable 



Occasion- 
ally pres- 
ent. 



May be 

present 

during 

pain. 

Present. 



Frequent. Xo. 



Gener- 
ally pres- 
ent. 

Present Present. 

with 
chills and 

sweats. 

May be 

present; 
variable. 



Often 

present. 



II. Inflammatory 

^ Disease. 
(a) Cholecystitis sub- Present; paroxysmal dur- Present 



(b) Cholecystitis 
acute. 



(c) Cholecystitis 
chronic (empyema 
of gall-bladder). 



(d) Cholecystitis in 
previously 
and contracted 
gall-bladder. 

(e) Cholangitis of 
hepatic and com- 
mon ducts 



III. Xew Growths. 
(a) Carcinoma of 
gall-bladder. 



(b) Tumor of cystic 
duct. 

(c) Tumor of hepatic 
or common duet. 

(<2) Tumor of neigh- 
boring viscera pro- 
ducing chronic ob- 
struction of_com- 
mon duct. 



May be 
present. 



Present. 

Present; 
intermit- 
j tent. 

: Present; 
progress- 
ive; may 
vary in 
intensity. 



Xo. 



ing periods of cystic duct during 

closure from stone or attacks 
swollen mucous mem-; of colic, 
brane. 

A.cute paroxysmal radiat- Present, Present; Xo. 
ing pain; extending to with often 

back and shoulder; may chills and severe, 

be very severe. sweats 



Present; often severe; par- 
oxysmal. 



Severe radiating pain at Present; Present 
first; may disappear severe at at first, 
later; tendency to recur, first, may 
diminish 

later. 
Present; Present, 
often 
with 
chills and 
sweats. 
May be absent; generally 1 Present; ' Present, 
present when obstruction chills; i 
exists, or severe infection;! sweats; 
tenderness and pain over severe 
liver in intrahepatic chol- prostra- | 
angitis. tion; gen- 

eral sep- 



Xo. 



Xo. 



Xo; may occur late in dis- 
ease. 



Xo; may occur late. 
Xo; may occur late. 
Xo; may occur late. 



Present; 
variable. 



Present 
late (por- 
tal 
glands). 



Xo. 



Present; 
progress- 
ive. 
Present; 
progress- 
ive; may 
become 
extreme. 



Xo. 

Rarely present, 

Rarely presents 



Present during 
attacks of cys- 
tic duct ob- 
struction. 

Present; tender- 
ness; ofterj 
muscular 
rigidity. 



Present; with 
tenderness; 
may attain 
large size. 

Xo (occasion- 
ally present! 
due to peri- 
cystic exudate). 

Xo. 



Hard, irregular, 

movable tumor 

at first, later 

diffuse 

infiltration. 

Present when 

obstruction 

exists. 

May be present 

from distention 

with bile. 
Present; gener- 
ally from dis- 
tention with 
bile. 



OTHER AFFECTIONS OF THE GALL-BLADDER AND DUCTS 735 
of the Gall-Bladder and Ducts. 



Urine. 


Stools. 


Liver. 


Spleen. 


Ascites. 


Remarks. 


Negative 


Normal. 


Not enlarged. 


Not enlarged. 


No. 


Generally discovered by acci- 
dent; often unrecognized. 


Negative. 


Normal. 


Not enlarged. 


Not enlarged. 


No. 


All symptoms promptly relieved 
as soon as obstruction removed. 


Negative. 


Normal. 


Not enlarged. 


Not enlarged. 


No. 


Hydrops of gall-bladder often 
unrecognized. 


Contains 


May be clay 


Frequently 


Not enlarged. 


No. 


Diagnosis extremely difficult; 


bile pig- 


colored if 


enlarged. 






symptoms generally due to co- 


ment at 


obstruction 








existing cholangitis. 


times. 


occurs. 










Contains 


Clay col- 


Not enlarged. 


Not enlarged. 


No. 


Symptoms rapidly disappear 


bile pig- 


ored. 








when stone passes papilla. 


ment. 












Contains 


Clay col- 


May be en- 


May be en- 


No. 


"Fievre intermittente he*pa- 


bile pig- 


ored. 


larged during 


larged from 




tique" of Charcot resembles 


,ment. 




attack. 


pressure of 
stone on vein. 




malaria; all symptoms disap- 
pear during interval. 


Contains 


Clay col- 


Enlarged. 


May be en- 


No. 


Condition may remain for many 


bile pig- 


ored. 




larged. 




years; may only be jaundice 


ment. 










with digestive disturbances 
and loss of weight; history of 
previous attacks (?). Ascites 
may be present from pressure 
of large stone or possibly from 






















hydrsemia. 


Negative. 


Normal. 


Not enlarged. 


Not enlarged. 


No. 


Tenderness over gall-bladder; 
tendency to recurrence; gener- 
ally associated with stones in 
gall-bladder. 


May con- 


Normal. 


Not enlarged. 


May be en- 


No. 


May follow typhoid or other sep- 


tain albu- 






larged (sepsis). 




tic diseases; onset often sud- 


min and 










den; rapid development of 


casts. 










severe symptoms resembling 
appendicitis; may be necrosis 
of wallsof gall-bladder with 
perforation; local or general 
peritonitis. 
Frequently follows acute chole- 


Negative. 


Normal. 


Not enlarged. 


Not enlarged. 


No. 












cystitis; occasionally becomes 












quiescent, presenting practi- 












cally no symptoms. 


Negative. 


Normal. 


Not enlarged. 


May be en- 
larged (sepsis). 


No. 


Generally tenderness over gall- 
bladder area, but no tumor; 
local peritonitis; diagnosis 
often extremely difficult. 


May con- 


May be 


'Enlarged. 


Enlarged 


No. 


Often follows severe infections 


tain bile 


clay 




(sepsis). 




of gall-bladder; generally asso- 


pigment, 


colored. 








ciated with stones in common 


albumin, 










or hepatic ducts; severe sepsis; 


and casts. 










generally fatal in virulent in- 
fections (streptococcus). 


Negative 


Maybe 


Enlarged late 


May be en- 


Present 


Digestive disturbances, progress- 


(at first). 


clay 


in disease. 


larged late 


late. 


ive loss of weight and asthe- 




colored 




(pressure on 




nia; cachexia; rapidly fatal. 




late. 




vein). 






Negative. 


Normal. 


Not enlarged. 


Not enlarged. 


No. (?) 


Very rare; both benign and ma- 
lignant growths have been re- 
ported; diagnosis difficult. 


Contains 


Clay 


May be en- 


Not enlarged. 


May be 


Very rare; diagnosis difficult. 


bile pig- 


colored. 


larged. 




present 




ment. 








late. 




Contains 


Clay 


Enlarged. 


May be en- 


Present 


Malignant tumors most common; 


bile pig- 


colored. 




larged late. 


late. 


chronic interstitial pancreati- 


ment. 










tis from previous infection of 
biliary passages may remain 
after cause has disappeared; 
enlarged portal glands; Hodg- 
kin's disease. 



736 DISEASES OF THE GALL-BLADDER 

Prognosis. — The prognosis is difficult to formulate. Stones may 
pass without recurrence of colic and the passage of smooth calculi may 
justify some hope that they are the only ones. The first attack is 
usually the worst. Fever, infection, cancer, and obstruction of the 
common duct and intestine must be covered in forecasts to patients 
refusing operation. Riedel held that 10 per cent, recover spontaneously 
under expectant treatment, while in 90 per cent, of cases surgical 
intervention is indicated. 

Treatment. — 1. Prevention. — Exercise and deep breathing aid the 
flow of bile. Lacing is a factor to be regarded. Plenty of water 
increases the secretion of bile. Digestive derangements should be 
corrected. Alcohol is contra-indicated. Kehr believes that food should 
be taken in small amounts at frequent intervals and should be chiefly 
nitrogenous, in order to favor the secretion of bile. The predisposing 
gall-bladder inflammation seldom comes under the physician *s care, but 
in suspicious cases, sodium salicylate, gr. x to xv t. i. d. given alternate 
weeks, acts as a cholagogue — increasing the bile two or threefold — and 
antiseptic. Mercurials seem to stimulate bile formation less than to 
aid in its evacuation. Potassium iodide and mild salines (sodium 
phosphate, 3 SS to j) are beneficial. 

2. Colic. — Hypodermics of morphine must be given, gr. \ being 
combined with nitroglycerine gr. jho and (for the first injection in the 
attack) with atrophine gr. fho', repeated doses of morphine and 
nitroglycerine are often necessary. Inhalation of chloroform is indi- 
cated in severe cases until the morphine acts, but none of these drugs 
should be left in the possession of any patient. A full hot bath and 
hot fomentations over the liver are valuable accessories. Drinking 
freely of warm water makes the vomiting easier, which in turn relieves 
the pain. 

3. Medical Treatment. — This in no way influences the solution of 
gall-stones. Durande's solvent (oil of turpentine 1 part to ether 4 
parts) is useless, and, like chloroform, is only antispasmodic. Olive 
oil at best only facilitates their final passage. Salicylates, calomel, 
salines (v.s.) and various "cures," as at Carlsbad, Vichy, Marienbad, 
Kissingen, Las Vegas or Bedford Springs, may be useful in quieting 
concomitant or causative inflammation. Local massage is obviously 
injurious. 

4. Surgical Treatment. — The author believes that gall-stones should 
be operated on when recognized, thus saving time, suffering, and danger. 
The following indications are given by Kehr : " (a) I recognize that the 
latent state ensues in many cases of cholelithiasis after rest cures or 
alkalies and in certain cases is permanent. Particularly in the so-called 
cases of chronic recurrent cholecystitis a regular rest cure carried out at 
Carlsbad, Neuenahr, or even at home, will often so mitigate the colics 
that all reason for operation will be absent. But I doubt whether an 
absolute cure will frequently occur, i.e., the passage of all the stones, 
by medical means. It is my opinion that we should never endeavor to 
force a passage of the stones; it is much better to seek to render them 



OTHER AFFECTIONS OF THE GALL-BLADDER AND DUCTS 737 

quiescent in the gall-bladder and secure a restitution of the inflamma- 
tory processes. The continuous use of hot applications for weeks, in 
conjunction with rest in bed and the use of Carlsbad waters, will give 
the best results. " (b) Riedel *s theoretical justification for early 
operation — the removal of the calculi while they remain in the gall- 
bladder — holds good now as ever, as in many cases an early operation 
is the only salvation for the patient against such grave dangers as per- 
foration, cholsemia and carcinoma. Universal application of early 
operation, however, in general practice, is absolutely impossible, and 
RiedeFs indications for operation are, for this reason, without practical 
value. " (c) I decline operative interference if the attacks run a mild 
course, and in the intervals when complete latency exists, i.e., entire 
absence of sensitiveness in the region of the gall-bladder. " (d) Acute 
obstruction of the choledochus is, with rare exceptions, to be treated 
medically. Should cholangitic symptoms appear, or should the jaun- 
dice be prolonged sufficiently to induce loss of strength and absolute loss 
of appetite, operation should be performed. " (e) Operation is nec- 
essary when frequent colics occur, even without jaundice or the passage 
of stones, which damage the general health, deteriorate the earning 
capacity, and destroy the pleasure of living. " (/) Cases of jaundice 
which are always accompanied by the passage of stones, belong to the 
physician; should the attacks multiply, the patient become vitally 
depressed, and no hope be present for the passage of all the stones, 
the propriety of the operation is established. " (g) Hydrops, empyema 
of the gall-bladder, and pericholecystitic abscesses belong to the pro- 
vince of surgery. In those rare exceptions in which a sterile hydrops 
gives rise to a few symptoms, the patient may be ignorant of his swollen 
gall-bladder until distress begins and multiplies. " (h) Surgical treat- 
ment should not be postponed too long after the failure of a Carlsbad 
cure. " (i) Gall-stone patients who have become addicted to the use 
of morphine must, under all circumstances, be operated upon. During 
the after-treatment the best opportunities are afforded for curing the 
opium habit. " (j) Treatment of carcinoma of the gall-bladder can 
only be of lasting benefit if the case is operated upon early. Every one, 
however, dreads an early operation, and late operations are not of 
much use; therefore the complete cure of the evil will but rarely be 
effected. " (k) Those suffering with chronic jaundice, which is not 
dependent upon stone in the common duct or incurable disease of the 
liver, must be operated upon, at the latest, three months after the 
appearance of the icterus, for it not infrequently occurs that in place 
of a suspected carcinoma of the head of the pancreas, a curable chronic 
interstitial pancreatitis will be found. " (/) The decision for operation 
will be rendered easy for both physician and patient upon demonstra- 
tion of tumor of the gall-bladder, a swollen liver, and the appearance of 
jaundice and fever. We may also operate on cases without demon- 
strable local lesions of the gall-bladder and liver, which exhibit severe 
and continuous symptoms which do not prove amenable to internal 
medication. We find in such cases, particularly often in men , adhesions 

47 



738 DISEASES OF THE GALL-BLADDER 

of traumatic origin without stones. " (m) The sequelae of cholelithiasis, 
purulent cholangitis, abscess of the liver, peritonitis due to perforation, 
subphrenic abscess, severe pyloric and duodenal stenosis, and gall- 
stone ileus, must be treated surgically. " (n) Concluding: To present 
general indications for a gall-stone operation is not readily possible. 
One must decide each case on its own merits. Men, particularly 
corpulent ones, do not bear the operation well. Women who have 
borne children lend themselves particularly well to this surgical pro- 
cedure. If possible one should refrain from operating in cases of 
diabetes, arteriosclerosis, chronic nephritis and diseases of the lungs 
and heart." 

In Mayo's 1,000 operated cases (1905), the mortality was but 1 per 
cent, in 416 uncomplicated cases, while those complicated by suppura- 
tion or cancer brought the average mortality to 5 per cent. ; the death 
rate in operations on the common duct was 1 1 per cent. These figures 
appear to the writer as the best possible argument for early operation. 
Cholecystotomy was attended by a 2.5 per cent, mortality and it is 
therefore the better operation, as cholecystectomy entailed 4.3 per 
cent, of fatalities. In Kehr's last 500 cases (1904), the mortality was 
3jper cent, in uncomplicated cases and 13 per cent, with cancer and. 
cholangitis; stones were left in 2.5 per cent., hernia developed in 3 per 
cent, and adhesions and inflammatory colic occurred in 5 per cent. 
(versus his earlier figures of 4, 7 and 17 per cent, respectively). 

(C). CHOLECYSTITIS. 

Etiology. — Inflammation of the gall-bladder may occur before, 
after, with or without inflammation of the bile passages, (a) Predis- 
posing factors are gall-stones (especially large ones which cannot pass, 
which cause 65 per cent, of cholecystitis and cholangitis (Dominici) or 
90 per cent, in other statistics), bile stasis, trauma, foreign bodies, or 
previous attacks, (b) The exciting cause is bacterial; the colon, 
typhoid, pyogenic, pneumococcus, cholera or influenzal organisms may 
be responsible. They may ascend the bile channels or enter with the 
blood current. Inflammation from typhoid infection (Louis and 
Andral) may occur without actual typhoid, or may develop even twenty 
years later (Osier). 

Symptoms. — The symptoms vary with the intensity of infection, 
which is almost synonymous with the type (simple, membranous, 
suppurative, phlegmonous, ulcerative, or gangrenous). In light forms 
the symptoms may not be recognized; this corresponds to post mortem 
adhesions in cases with no history of cholecystitis. In other cases, 
perhaps more severe ones, symptoms are obscured by the causative 
typhoid, or by gall-stones. In the average case, there is (a) pain over 
the part, which may be severe or paroxysmal and may radiate toward 
the appendix or back, (b) Tenderness as in gall-stones; it is often 
first general and then local, and the right rectus is tense; it is clearly 



CHOLANGITIS, CATARRHAL ICTERUS, CONGENITAL OCCLUSION 739 

elicited by a jab over the part during inspiration, (c) Fever, increased 
pulse rate, vomiting or nausea; fever is absent in mild infections: in 
typhoid, cholecystitis, may be confused with typhoid relapse (Musser), 
(d) There may be a palpable gall-bladder. Its contents may be puru- 
lent (empyema cystidis fellese) or serous (hydrops cystidis fellese). 
Hydrops may enlarge the gall-bladder to the size of the fist, or in 
extreme cases so that it weighs 50 to 60 pounds, contains thirty to 
forty quarts, and fills the entire abdomen ; experienced observers have 
mistaken such cases for ascites; the fluid is alkaline or neutral, serous 
or mucoid. If very tense the gall-bladder may not fluctuate or if very 
lax may not be palpable (see Floating Kidney). There may be pus 
in the gall-bladder without enlargement. In chronic cases it may 
shrink, (e) Severe sepsis may intervene when there is diffuse sup- 
purative cholangitis or pylephlebitis; this is evidenced by septic fever, 
chills, leukocytosis, colon bacilli, pneumococci or other organisms in the 
blood, swollen liver and spleen, nephritis, and ulcerative endocarditis. 
Icterus is inconstant. 

Prognosis. — Many cases with cholangitis die in spite of operation. 
Mild cases may subside, but recurrence and formation of gall-stones are 
frequent. Under expectant therapy, the outlook is serious in severe 
cases, for perforation, localized or general peritonitis, adhesions (in 
75 per cent.), and duodenal or pyloric obstruction may result. 

Treatment. — Rest, milk diet, local heat and morphine may suffice 
for light cases, but in the more severe infections drainage is indicated. 



(D). CHOLANGITIS, CATARRHAL ICTERUS, CONGENITAL 

OCCLUSION. 

Suppurative cholangitis usually is diffuse, co-exists with suppurative 
cholecystitis and results from gall-stones with infection. It may occur 
in cancer or foreign bodies in the tracts and in pylephlebitic liver 
abscess. The infection is usually ascending but may follow infection of 
the portal vein into which their bloodvessels empty. The symptoms 
of cholangitic sepsis have been described under cholecystitis. Drain- 
age is indicated. 

Acute catarrhal jaundice (cholangitis catarrhalis, icterus simplex 
seu gastroduodenalis) results from gastroduodenal catarrh which 
causes swelling with obstruction of the papilla, and probably catarrhal 
inflammation of the lower portion of the common duct; as few cases 
come to autopsy, the latter point is not entirely proven, though a small 
plug of mucus usually occludes the opening. Its usual causes are 
practically those of acute gastritis or enteritis. Favoring factors 
include passive congestion (cardiac or portal), acute infections, toxic 
causes (as phosphorus), nephritis, other diseases of the liver or bile 
tracts (cirrhosis, cancer, stones, parasites), and very rarely psychic 
disturbance or menstrual derangement. Epidemic forms occur or 
forms which seem to be a separate type of infection (^.Weil's Disease). 



740 DISEASES OF THE BILE TRACTS 

Symptoms. — Gastro-intestinal catarrh occurs first in many cases 
and after a few days to a week or so icterus appears, with its usual 
symptoms {v. Icterus), sudden decolorization of the stools, and bright 
yellow staining of the skin and urine. However the physician must 
not expect to always find an antecedent gastroduodenitis, because 
a primary infectious catarrh of the bile ducts is equally frequent. 
Other findings are inconstant; the liver is not enlarged at first, but 
may become slightly swollen later; there is no pain over the liver or 
duct*s, emaciation if present is slight, the spleen and gall-bladder are 
seldom enlarged, and the diagnosis depends entirely on the mode of 
onset in young, healthy subjects, sequence of symptoms and exclusion 
of other causes of obstruction. In advanced life, catarrhal jaundice is 
uncommon and gall-stones and cancer are always to be thought of first. 

Prognosis. — The prognosis is almost always good, the jaundice 
lasting four to eight weeks. The author has seen cases clear in a week 
and others last five months, though a course of over four to eight weeks 
renders the diagnosis uncertain. Cases with fever may run a pro- 
longed course. Death rarely occurs. Cases of[f atal hemorrhage (Toelg 
and Neusser), and in the aged, of exhaustion (Leichtenstern), and 
of sudden death with symptoms of sudden heart-failure, are reported. 

Treatment. — (a) Causative factors, as gastritis or cardiac failure, 
should be appropriately treated; dyspeptic symptoms yield most 
readily to gastric lavage ; a diet of skimmed milk, which contains least 
fat, and fractional doses of calomel at night followed by a mild saline 
in the morning, should be given; but it should be remembered that 
active catharsis augments or indeed initiates catarrh. 

Acidi hydrochlorici diluti . . . Sj. 

Tincturse nucis vomicae 5iv. 

Tincturse gentianae co q.s. ad §iv. 

M. et S. — One teaspoonful after meals in half a glass of water. 

Calomel was formerly given because it produced green "bilious 
stools"; this color is not due to bile but to mercuric sulphide, (b) 
In the diet, fats are particularly to be avoided, as neither the stomach 
nor intestine can digest them; tea, coffee, alcohol and coarse foods 
should be interdicted; as above mentioned, skimmed milk is given and 
well-cooked carbohydrates are gradually added to the diet; toast, 
eggs, mealy soups and possibly some lean meat may be given, though 
meat is often poorly tolerated, seemingly because of exclusion of the 
pancreatic secretion, (c) As long as acute dyspepsia exists, rest in bed 
is indicated, in order to maintain nutrition on the lowest possible diet. 
(d) The bowels should be regulated by copious injections of water 
which are thought to incite peristalsis and therefore dislodge the 
obstructing mucus plug, (e) The itching is allayed by 1 per cent, 
carbolic solution, the use of which requires care, as the urine some- 
times becomes cloudy; acetanilide, gr. v q.i.d.; potassium bromide, 
5ss, well diluted, by rectum once or twice daily; an occasional hypo- 
dermic of pilocarpin hydrochlorate gr. -J, warm baths to relieve the 



CANCER OF THE GALL-BLADDER 741 

dryness of the skin and calcium chloride gr. x to xx t.i.d. for a few 
days are indicated. 

Chronic catarrhal cholangitis rarely follows the acute form but more 
often results from occlusion of the common duct by calculus, cancer, 
stricture or pressure from without (v. gall-stones, pancreatic cancer and 
icterus) . 

Congenital Occlusion of the Bile Ducts. — Sixty-four cases are re- 
corded, according to Rolleston, who thinks that some poison possibly 
initiates cholangitis, which results in a mixed cirrhosis and obliteration 
of the ducts. Icterus develops within a month after birth and death 
results in a few weeks or months — nearly always within a year — from 
cholsemia or hemorrhages. 



(E). TUMORS OF THE GALL-BLADDER AND BILE VESSELS. 
Cancer of the Gail-Bladder. 

Tumors other than cancer are rare and of purely anatomical interest 
as papilloma, fibroma, lipoma, or adenoma. Rolleston states there are 
but 9 recorded cases of sarcoma. Fiitterer (1901) collected 268 cases 
of cancer, though it is certainly much more frequent than these figures 
indicate. 

Etiology. — The most striking etiological factor is gall-stones, 
present in 70 per cent. (Musser, Fiitterer) to 85 per cent. (Zenker, 
Courvoisier) ; it is estimated that 4 to 14 per cent, of cases of gall-stones 
result in cancer of the gall-bladder, but this seems a very high percent- 
age considering the great number of cases of gall-stones and the small 
number of cases of cancer of the gall-bladder. Eighty per cent, occurs 
in women, caused by lacing (Fiitterer); the average age of subjects is 
fifty-eight years. 

Pathology. — The tumor may be scirrhus or medullary, but histo- 
logically is usually of the columnar type (adenocarcinoma); the 
spheroidal and squamous types are rare. 

Symptoms. — (a) Gall-stones which irritate the mucosa and cause 
most cases, usually produce no symptoms though previous colic may be 
noted in the history, (b) A tumor of the gall-bladder is palpable in over 
66 per cent., first as a smooth oval swelling, and later as a larger and 
more nodular one; it is usually due to the growth, for the gall-bladder 
itself is generally shrunken. The fundus is the usual point of origin, 
being most irritated by calculi ; much more rarely the neck of the gall- 
bladder, or least frequently, the cystic duct, is the point of origin. The 
tumor appears below the edge of the liver with which it moves and with 
which it is consecutive on palpation, percussion, and on inflation of the 
colon. There may be local discomfort and, in rare cases, severe pain 
like that of gall-stones, (c) Cachexia appears with all its attendant 
symptoms. 



742 DISEASES OF THE BILE TRACTS 

Complications. — Secondary growths in the liver occur in 58 per cent, 
by lymphogenous routes or by invasion from contiguity and sometimes 
cause hepatic enlargement; from the liver, extension by the hepatic 
veins may occasion systemic metastases. Icterus occurs in 69 per cent. 
(Musser) from malignant or inflammatory involvement of the bile 
ducts; cholsemia is a common termination. Using Musser's figures, 
growths in the peritoneum occur in 12 per cent., in the lungs or pleura 
in 10 per cent., in the abdominal lymph glands in 16 per cent, and 
ulcerative fistula into the colon in 10 per cent. Warthin records adrenal 
metastases with pigmentation like that of Addison's disease and with 
vitiligo. Pressure on the pylorus may cause its stenosis, vomiting, or 
dyspepsia. Ascites occurs in 25 per cent., and is due to mechanical 
compression of the portal vein or to malignant peritonitis. Suppurative 
cholecystitis and cholangitis may develop, and the case then terminates 
by sepsis, ulcerative endocarditis, etc. The differential diagnosis is con- 
sidered under gall-stones. The clinical course averages six months. 
Treatment is merely palliative, unless the affection is diagnosticated 
early enough for operation or is accidentally found in operating for 
other conditions. Removal of the gall-bladder cancer has resulted 
in a few permanent cures (Hochen egg, Robson, Warren). Part of 
the liver also must usually be removed. 



Tumors of the Extra-Hepatic Bile Ducts. 

Rolleston states that about 80 cases are reported. These tumors are 
usually small, show little tendency to infiltrate and are cancers of the 
columnar type. The common duct is most often affected, the hepatic 
duct much less frequently, and the cystic duct least frequently; these 
tumors usually occur between the years of sixty and seventy and two- 
thirds occur in males (Devic and Gallaverdin). The salient symptom 
is icterus, which develops early, increases steadily, is intense, occurs in 
nearly all cases, causes icteric necrosis of the liver cells in the central 
zone (Fiitterer) and precipitates early cholsemia before metastases have 
time to develop. The gall-bladder is almost always dilated anatomi- 
cally in tumors of the common duct and is felt clinically in over 50 per 
cent. Pain is not common, though that of gall-stones may be simulated. 
Ascites, dyspepsia and gastro-intestinal hemorrhages (from cholsemia) 
may develop. Death results most often from cholsemia, and less often 
from cholangitic sepsis. Differentiation from duodenal or pancreatic 
tumors (q.v.) is always difficult, indeed usually impossible. Confusion 
with gall-stones (q.v.) is possible. Palliative treatment consists'' of 
draining the gall-bladder to relieve the icterus; radical treatment' is 
extirpation of the deeply located tumor (Kehr, Halsted). 



ACUTE PANCREATITIS; FAT NECROJSIS 743 

DISEASES OF THE PANCKEAS. 

(A). ACUTE PANCREATITIS; FAT NECROSIS. 

Etiology. — Infection ascending from the intestines is the leading 
cause, (a) Calculus obstructing the common duct, though allowing bile 
to regurgitate into Wirsung's duct, may cause acute pancreatitis (Opie), 
especially when the gall-bladder, the natural reservoir for obstructed 
bile, is shrunken. Japha found gall-stones in 38 per cent, of 76 cases of 
acute fat necrosis of the pancreas. According to Quenu and Duval 
(1906) 118 cases are recorded in which pancreatitis occurred in the 
course of cholelithiasis. Flexner concludes that gastric juice, and Opie 
that bile alone may initiate inflammation and fat necrosis, even when 
there is no infection. Though the accessory duct of Santorini may 
carry off the pancreatic juice when there is obstruction of Wirsung's 
duct, it is too small for much compensation in 66 per cent, of cases 
(Opie); (b) metastatic infection is an infrequent cause; in one case the 
author observed acute pancreatitis in which acutely inflamed ulcers of 
the leg may have been the atrium of infection; it rarely follows 
mumps; (c) in some cases suppuration or ulceration in contiguous 
tissues is causative. 

Predisposing Factors. — (a) Age and sex; in Koerte's collection of 
41 cases, 90 per cent, occurred in males beyond middle life; McPhedran 
observed a case in a child nine months old. (6) Obesity; (c) alcohol- 
ism; (d) trauma; and (e) gastro-intestinal catarrh are factors. (/) 
Parturition appeared to be a factor in 6.6 per cent, of Peiser's collection 
of 128 cases. 

Symptoms. — The symptoms were clearly described and the clinical 
picture defined by Fitz (1889), though cases were reported earlier 
(Oppolzer). The onset is sudden in adult stout males who have enjoyed 
previous good health, or who have a history of alcoholism or of gall- 
stones. 

1. Epigastric pain is the initial symptom; it is very sudden and 
severe, is often agonizing, may be constant or paroxysmal, and may be 
confused (or coincident) with gall-stone colic, though it is even more 
intense; it may be central, diffusely epigastric, to the right or left of the 
median line, or rarely directly over the head of the pancreas. The 
author has seen cases in which it radiated into both lower axillae. The 
intensity of the pain is referable to pressure on the cceliac plexus 
(neuralgia or possibly neuritis cceliaca). Much less often the pain is 
gradual in onset. 

2. Epigastric tenderness is usual, often over the head (Elliot) or 
sometimes more to the left and over the tail of the pancreas, whence the 
inflammation may extend to the left pleura with tenderness and friction, 
as in one of the author's reported cases. The recti are tense and the 
epigastrium is swollen. 



744 .DISEASES OF THE PANCREAS 

3. Vomiting is early and severe, and brings up food, mucus and 
sometimes blood. 

4. Collapse soon follows; it is often very severe, threatens im- 
mediate dissolution and too often prevents surgical interference. It is 
due to pressure, on or actual inflammation of, the closely contiguous 
cceliac plexus and semilunar ganglia. There may be marked cyanosis. 
In one of the author's cases there was relapsing shock with cyanosis 
and a pulse of 140, which was so weak that no surgeon would operate 
during the two weeks before recovery. Collapse usually causes death 
in 2 to 4 days in unoperated cases, 

5. Fever is not constant; there may be no elevation or an irregular 
rise to 103 or 104 degrees. Chills are more common in late suppuration 
than at the onset. 

6. The pancreas can rarely be felt because of its deep position behind 
the colon and stomach, and because the epigastrium is tense, swollen, 
and tympanitic. If palpable it is small and immobile. 

7. The bowels are constipated, simulating obstruction. Operation 
or autopsy at this stage shows an acute pancreatitis, with swelling, a 
variegated yellow-red or black color, exudation of fibrin, pus cells, 
blood (hemorrhagic pancreatitis) and areas of acute fat necrosis (Balser, 
1882). Fat necrosis is caused by the fat-splitting steapsin (Langerhans, 
Hildebrand, Dettmer and Flexner), which produces glycerine and in- 
soluble fatty acids from the pancreas and contiguous adipose tissues, 
i.e., omentum, mesentery, and peritoneum; the glycerine is absorbed, 
the fatty acids are precipitated with lime and become opaque white 
areas of necrosis as large as a pinhead or saucer, and some of the fer- 
ments occasionally escape into the blood, producing toxsemic symptoms 
or necrosing fatty tissue elsewhere, as in the pericardium or skin. 

8. If the patient lives, the symptoms of localized peritonitis develop 
in the upper half of the abdomen and sometimes more to the left side ; 
a pus sac may fill the lesser peritoneal cavity; the localized pain may 
become general from diffused fat necrosis. In one of the author's cases 
great dyspnoea attended diaphragmatic pleurisy. 

9. Septicopyemic symptoms may appear, as rigor, hectic fever, 
delirium, pleurisy, hiccough, icterus, diarrhoea, and loss of weight and 
strength ; in one case the author saw acute splenic tumor, acute nephri- 
tis and universal swelling of the lymph nodes. 

9. Acute glycosuria is not common, though present in one of the 
author's cases. 

In the third week rupture into the colon may occur; this is attended 
by lancinating pain, intestinal hemorrhage, even passage of the pan- 
creas by the bowel (Chiari) and relief from all symptoms. 

Suppurative types, of which Koerte collected 46 cases, may begin 
gradually, without acute gangrene, fat necrosis, or hemorrhage. The 
symptoms are less acute and severe than those of the acute type. The 
suppuration is localized or there is a diffuse purulent infiltration; it 
may cause pylephlebitis, liver abscess, subphrenic abscess, burrowing 
of pus into the peritoneum, loin (which Koerte considers rather char- 



ACUTE PANCREATITIS; FAT NECROSIS 745 

acteristic), peripheral tissues, or alimentary tract. Protracted suppura- 
tion sometimes is said to cause glycosuria, skin pigmentation, and 
anasarca. Koerte found 40 cases of acute gangrenous pancreatitis. 

Diagnosis. — The cardinal features are (a) the sudden onset, (b) 
violent epigastric pain and tenderness, (c) vomiting, (d) collapse, (e) 
epigastric distention. The absence of indican under circumstances in 
which it usually is increased is suggestive of pancreatic lesions, because 
trypsin converts albumin into peptone, which in turn becomes partly 
converted into indol, the source of indican in the urine. Since leucin 
and tyrosin are formed in the normal intestine as a result of the action 
of the pancreatic juice upon proteids, Ulrich attaches much importance 
to their absence from the urine (with glycosuria), as indicative of 
disease of the pancreas. Robson finds calcium oxylate crystals in 30 
per cent, of all varieties of pancreatic disease. 

The pancreatic reaction of Robson and Cammidge is a test for gly- 
cerine in the urine; it is complicated and recent reports show it is 
neither constant nor reliable. 

Differentiation. — (a) Acute poisoning is eliminated by the history 
and by the gastric contents. (6) Intestinal obstruction is less severe 
in onset; collapse is usually attended by distention and often by 
intestinal rigidity or peristalsis above the obstruction, and rectal 
injections often show its impermeability; indicanuria is usual; epi- 
gastric distention alone is unusual; in one pancreatic case, the author 
saw obstruction lasting nine days. Operation, indicated in either 
instance, may be necessary for diagnosis, (c) Gall-stone colic is some- 
times hard to differentiate but is rarely as severe as pancreatic pain; 
collapse or epigastric distention is infrequent, (d) In perforating 
duodenal or gastric ulcer, the later collapse, pain, and the history, are 
significant, (e) Mesenteric embolism and appendicitis (without in- 
duration) must be considered. 

Prognosis. — Mild cases may occur, though the malady generally 
evinces a severe progressive tendency. A fatal attack may be the 
last of several milder seizures. Fitz has found at autopsy fibrous 
tissue and crystals or granules of hsematoidin which he regards as 
evidence of previous hemorrhage and inflammation. Death may occur 
within a few hours to three days from collapse, in two or three months 
from sepsis, or in six months from diabetes (Fitz). Death at an even 
later period may result from sepsis or diabetes. Koerte and Osier 
report cases of recovery after cceliotomy had first revealed the true 
cause of the obstruction. The pancreas may slough into the intestine, 
as in Trafoyer's and Chiari's cases, and recovery may result. 

Treatment. — Rectal feeding and stimulation, morphine hypoder- 
matically, and heat are indicated during the initial shock, from which 
some surgeons consider that a rally is necessary before operation can 
be safely performed. Though early operation is dangerous because of 
shock and hemorrhage, the author considers, with Robson, that it 
is indicated lest local extension or general toxaemia develop. In 21 
cases (Quenu and Duval), 62 per cent, of the acute cases died after 



746 DISEASES OF THE PANCREAS 

operation, 100 per cent, of the hemorrhagic, and 45 per cent, of the 
acute suppurative cases. 



(B). CHRONIC PANCREATITIS, 

Etiology and Pathology. — (a) Gall-stones in the common duct may 
induce chronic catarrh of Wirsung's duct, thus leading to chronic 
pancreatitis (Robson). (b) Cancer, gastroduodenal catarrh and ulce- 
ration (alcoholism, syphilis, and pancreatic calculi) may produce the 
same results. In these instances ascending injection appears to be the 
patent factor, causing interlobular fibrosis (Opie) i.e., fibrosis around 
the pancreatic lobules; diabetes is a late and uncommon sequence, 
(c) In liver cirrhosis and hemochromatosis (see Diagnosis Portal 
and Biliary Cirrhosis) an interacinar fibrosis (Opie) occurs, develop- 
ing in the lobules, diffusely invading the islands of Langerhans and 
causing glycosuria ; it does not result from obstruction of the common 
duct. The opposite of this condition was described by J. C. Ohlmacher 
in a case of degeneration of the liver; there was a compensatory hyper- 
trophy of Langerhans' islands, proving for the first time the mutual 
relation of the pancreas and liver, in diabetes, and in the disposition 
of carbohydrates. 

Symptoms. — Symptoms may be lacking. Moynihan states that 
chronic inflammation increases in frequency with increasing thorough- 
ness of operations for gall-stones. They vary with the cause. In 
catarrh due to gall-stones there is a history of colic, jaundice, and some- 
times intermittent fever. Tenderness in the epigastrium, a fulness 
above the umbilicus, and loss of flesh are noted, and if the pancreatic 
symptoms predominate, the pain passes from the epigastrium to the 
left side, to the scapular or renal regions. If gall-stones are not the 
cause, there may be merely aching or painful attacks which are not 
at all pronounced; pain may be absent. The gall-bladder may enlarge 
from obstruction of the common duct, when the liver becomes enlarged 
and frequently cirrhotic (Robson). According to Robson marked 
enlargement of the spleen is frequent, bile is found in the urine in 60 
per cent., calcium oxalate crystals in 40 per cent, and glycosuria in 
but 5.5 per cent. (90 cases). Opie found glycosuria but once in 22 
cases. Riedel, Koerte, Robson, Moynihan, and others have described 
a tumor-like induration of the head of the pancreas, which simulates 
cancer because of the emaciation and icterus which it produces; 
differentiation may be impossible, even during laparotomy; it is more 
common in subacute than in chronic cases. As in tumor, excessively 
copious, pale stools, laden with fat and undigested muscle-fibers, are 
noted. Polyuria has been reported. 

Differentiation from stone in the common duct and from cancer 
is very difficult. 

Prognosis. — Without surgical intervention, death is likely to occur 
from emaciation, cholsemia, diabetes, or hemorrhagic diathesis. 



PANCREATIC LITHIASIS 747 

Treatment. — In severe clear cases and doubtful cases drainage of 
the gall-bladder or anastomosis is indicated. Robson operated on 
62 cases with 13 per cent, mortality, Quenu and Duval on 62 cases 
with 13 per cent, mortality, and Moynihan on 14 cases without a 
death. Hemorrhage is a dreaded complication; Robson and Moyni- 
han recommended calcium chloride gr. xx to 5 j t.i.d. before operation 
to increase the coagulability of the blood. 



(C). PANCREATIC APOPLEXY. 

Pancreatic hemorrhage has been described by Spiess (1866), Klebs 
(1870), and Zenker (1876). Draper found 19 instances in 4,000 autop- 
sies and Anders (1899) collected 40 cases. The anaemias, syphilis, 
alcoholism, obesity, acute infections and local lesions of the pancreas, 
seem to be predisposing causes. Sixty-six per cent, of cases occur in 
men. Doubtless many reported cases are acute hemorrhagic pan- 
creatitis. Sudden onset, severe collapse, epigastric pain, intestinal 
obstruction, vomiting, restlessness, and normal or subnormal tem- 
perature, mark the affection. The course is said to be even more 
acutely fatal than that of acute pancreatitis; death sometimes occurs 
within a few hours. If the patient survives the initial stage, suppura- 
tion may develop in the pancreas, peritoneum, and retroperitoneal 
tissues into which the hemorrhage sometimes burrows. Hemorrhagic 
cysts may form, which should not be confused with cysts into which 
secondary hemorrhage has occurred. The diagnosis from acute pan- 
creatitis is rarely made, and the treatment of both affections is iden- 
tical. 

(D). LITHIASIS. 

Few more than 100 cases of sialolithiasis pancreatica are recorded. 
The etiology is probably like that of gall-stones, infection of Wirsung's 
duct (wirsungitis) ; stagnation of secretion is a predisposing factor, 
whence the occasional association with gall-stones, pancreatic inflam- 
mation and tumor. 

Symptoms and Diagnosis. — Confusion with gall-stones is often 
inevitable, for colic without icterus is equally indicative of either 
condition and their co-existence is not uncommon. The pain ma\ 
radiate to the left side and shoulder; Lancereau, Lichtheim, Leichten- 
stern, Minnich, Holtzmann, Moynihan, and Kinnicutt have recognized 
cases. In some of them the stones were found in the faeces during life, 
in others at autopsy. Salivation is reported. In Lichtheim's case 
there was colic, glycosuria (found in 33 per cent, of the cases) and 
diarrhoea. The stones are single or multiple (even 300), white-gray, 
round, oval, irregularly outlined or branching, hard or friable, and 
vary in size from that of almost impalpable gravel to that of a hazel- 
nut. They consist largely of calcium carbonate and phosphate. 



748 DISEASES OF THE PANCREAS 

Shattuck described an oxalate calculus. Their sequelae are (a) ob- 
struction and inflammation of Wirsung's duct, (b) acute suppurative 
pancreatitis and possibly pancreatic cancer. The treatment, in the 
cases which are fortunately diagnosticated, is surgical; Moynihan 
both recognized and successfully operated on a case. Gould also 
operated on a case which did not recover. 



(E). PANCREATIC CYSTS. 

To Nicholas Senn (1885) belongs the credit of establishing their 
clinical picture. Bessel-Hagen (1900) collected 149 cases. 

Etiology and Pathology. — Probably many reported cases are extra- 
pancreatic, especially (a) the traumatic cysts of which Honigmann in 
1905 collected 69 cases, (b) Duct obstruction (ranula pancreatica, 
Virchow) by calculi, strictures, parasites, tumors, or inflammation in 
the smaller ducts, is an etiological factor, (c) Cystadenoma is the 
cause of most cysts (Lazarus), (d) Cysts rarely result from an old 
hemorrhage. In all forms the cyst causes considerable parenchy- 
matous atrophy, (e) Sex. Traumatic and inflammatory forms are 
most frequent in men and the cystadenomatous type in women. 
(/) Age; over 50 per cent, are found in persons in the third decade 
of life, though a congenital form, sometimes with cystic liver and 
kidneys, is found (Richardson). 

Symptoms and Diagnosis. — 1. In cysts, (a) a deep retroperitoneal 
swelling is found, (b) the location of which is more or less central, 
but is above the navel in 87 per cent., where other cysts are most 
uncommon; it lies behind or between the stomach and colon; it 
sometimes lies below the colon but rarely above the stomach; very 
large cysts (which contain 10 to 20 quarts) may fill almost the entire 
abdomen. A cyst may in rare cases develop in the tail of the pancreas, 
when it points toward the spleen or left kidney, (c) Its form is round, 
oval, and smooth; (d) its consistence often varies; (e) it is immobile 
on palpation and on inspiration, or at the most can be moved slightly 
in a vertical direction. (/) The fluid is alkaline, 1,010-25 specific 
gravity, usually mucoid, blood stained in 82 per cent. (Koerte), and 
in 45 per cent, contains one or more pancreatic ferments (diastatic, 
saponifying, or tryptic) of which the latter is alone characteristic, for 
the other ferments occur in various exudates. The fluid sometimes 
contains fat and cholestearin ; aspiration is dangerous, because the 
tension of the cyst is great and fat necrosis or peritonitis may result 
from leaking after exploratory puncture. 

2. The so-called pancreatic symptoms are rare, as emaciation, sali- 
vation, stools laden with undigested fat or muscle-fibers or glyco- 
suria. 

3. Symptoms of peritonitis or of intestinal obstruction may occur in 
traumatic or inflammatory types and after rupture. The author saw 
a case of Murphy and Wittwer in which the picture after rupture 



PANCREATIC CYSTS 749 

was exactly that of subacute tuberculous peritonitis; after two rup- 
tures the case was successfully operated on. 

4. Pain like that of cholelithiasis may be present, but it more often 
radiates to the left side, shoulder and neck. Pressure symptoms in- 
clude dyspnoea, vomiting, icterus, emaciation, and polyuria. 

Differentiation from ovarian, renal and other cysts is largely a 
topographical question. Ovarian cysts have their pelvic origin and 
connection, but hydronephrosis is movable and originates in the flank 
to which pancreatic cysts seldom penetrate. Fluid in the lesser peri- 
toneal sac or mesenteric, omental, and retroperitoneal cysts are difficult 
to distinguish. Cysts of the liver present respiratory excursion and other 
obviously hepatic symptoms. 

Treatment. — Aspiration is never permissible. Enucleation of the 
sac is more difficult and more dangerous than simple drainage. In 
Bessel-Hagen's 149 cases, the operative mortality was 6.7 per cent. 
Diabetes has followed operation (Bull and Kroenig). 



(F). TUMORS OF THE PANCREAS. 

Cancer of the pancreas constitutes 67 per cent, of all pancreatic 
diseases but possibly this estimate must be discounted because con- 
fusions with benign induration have been frequent until of late years. 
It occurs in 0.6 per cent. (Eppinger) to 1 per cent. (Soyka) of autopsies. 
In 132 cases of pancreatic tumors (Segre) 127 were cancer, 2 sarcoma, 
2 cysts and 1 gumma. Sarcoma is usually secondary from contiguous 
lymphosarcoma in the retroperitoneal glands. 

Cancer is usually scirrhus, less often of the medullary, colloid, or 
adenomatous type. It most often begins in the head of the organ. In 
some cases it may be secondary to pyloric cancer. 

Symptoms. — (1) Tumor is the commonest and surest symptom, 
occurring in 25 to 50 per cent. ; it lies deep, beside the spine at the level 
of the navel and between the pylorus and colon. It is tender, prac- 
tically immobile, and varies from the size of a walnut to that of a child's 
head though small tumors are commonest; in some instances it may 
show propagated pulsation from the aorta or a bruit from its com- 
pression. Palpation should be made with the stomach and bowels 
empty. (2) Icterus occurs in 72 per cent., increases gradually, and 
is more often continuous than remittent. In some cases there may be 
rigors and pain as in biliary calculi; occasionally, just before death, 
the growing anaemia seems to lessen the jaundice. There may be the 
slightly enlarged "icterus liver," but Bard and Pic state the liver is 
usually rather small. (3) The gall-bladder is usually enlarged (Bat- 
tersby, Bard and Pic); see differentiation. Cochez holds that it 
shrinks when the hepatic or cystic ducts are obstructed. (4) Pain 
and early vomiting are usual. The pain is epigastric, severe, and 
sometimes neuralgic (neuritis cceliaca) or radiating as in pancreatitis 
or lithiasis. (5) Cachexia is marked and rapid ;•" great prostration, 



750 DISEASES OF THE PANCREAS 

emaciation, and a syncopal tendency occur in tumor as in other pan- 
creatic lesions. The temperature is usually subnormal. (6) The 
stools may contain much fat (Kuntzmann, 1827 and Bright, 1833); 
in steatorrhea the fatty acids and neutral fats (Mueller) are more 
abundant than the fatty soaps; its significance grows if diarrhoea and 
icterus are not present. The stools also contain many undigested 
muscle-fibers (lientery) and sometimes blood is present. (Sahli's 
test for albumin digestion is made by giving salol in divided doses in 
glutoid capsules; as the glutoid is not dissolved, no carbolic acid 
appears in the urine). (7) The urine may contain sugar; Mirallie* 
holds that glycosuria occurs in 26 per cent., though in Robson's 15 
cases it was absent. It is said to be an early symptom and to disappear 
before death or with the increasing icterus. Albuminuria is more 
frequent than glycosuria. The indican is decreased. Peptone, maltose 
(once, by v. Ackeren), and fat (Clark and Bowditch), have been found. 
Polyuria and bronzing of the skin are rare findings. Complications 
include pyloric or duodenal obstruction; compression of the aorta 
or cava; retention cysts of the pancreas; and extension by contiguity 
to the portal vein, colon, peritoneum, ureter or lungs. 

Differentiation. — 1. Chronic pancreatitis with icterus and tumor 
may not be differentiated even by laparotomy (Riedel) though ascites 
indicates neoplasm, and recovery means inflammation. The pan- 
creatic cachexia of French writers, occurring in many lesions of the 
pancreas, may be confused with the cachexia of cancer. 

2. In duodenal cancer (q. v.) the growth is also fixed and is attended 
by icterus, but cancer above the papilla causes rather the picture of 
pyloric stenosis; in cancer below the papilla, pancreatic juice may be 
recovered from the stomach. 

3. Liver disease, with the frequent icterus, ascites, and splenic 
enlargement, causes little difficulty in differentiation. 

4. Calculus in the Common Duct. — vs. — Compression of Common Duct by 

Pancreatic Tumor. 

1. History of colic usual. Absent. 

2. Tenderness of gall-bladder usual. Absent. 

3. Icterus, often remittent. Permanent. 

4. Liver less large than in — pancreatic tumor. 

5. Intermittent fever, and rigors. Subnormal temperature. 

6. Gall-bladder (see gall-stones) shrunk- Dilated in 92 per cent. (Courvoisier's 

en in 80 per cent. law). 

7. Slower^course. Very rapid emaciation. 

According to Bard and Pic, the icterus, enlarged gall-bladder, rapid 
emaciation, cachexia, subnormal temperature and normal or smaller 
liver of pancreatic cancer can only be confused with some few cases 
of gall-stones, cancer of immediately adjacent parts, primary cancer 
of the liver or bile-passages, and primary duodenal or gastric cancer 



ACUTE DIFFUSE PERITONITIS 751 

with early diffuse generalization in the liver. Kehr states that obstruc- 
tion of the common duct is cancerous in 70 per cent., (chronic) pan- 
creatitic in 20 per cent, and calculous in 10 per cent. 

Treatment is largely symptomatic; morphine should be given for 
pain, the gall-bladder should be drained (cholecystotomy) or it should 
be sutured to the intestine (cholecystduodenostomy). Koerte reports 
ten operations with six permanent recoveries, and Ruggi reports a 
successful operation. 



DISEASES OF THE PERITONEUM. 

(A). ACUTE DIFFUSE PERITONITIS. 

Acute inflammation of the peritoneum was at one time far more 
important as an independent affection than at present; we now regard 
it as chiefly symptomatic of some other disease, e.g., appendicitis, 
salpingitis, puerperal sepsis, etc. 

Etiology. — The actual cause is probably always mycotic. Some 
writers classify peritonitis as bacterial (especially suppurative forms), 
chemical (serous and sero-hemorrhagic forms) and mechanical (adhe- 
sive forms). The Streptococcus pyogenes (puerperal and traumatic 
forms), and Bacillus coli (forms due to intestinal lesions) are the two 
most frequent organisms. The staphylococcus, pneumococcus, and 
tubercle bacillus are fairly frequent and less often the Bacillus pyo- 
cyaneus, proteus, anthracis, typhosus, aerogenes encapsulatus, the ray 
fungus, Bact. lactis, gonococcus, Amoeba coli, and pseudodiphtheria 
organisms. Generally speaking, mono-infections are less common 
than mixed infections. 

Factors causing lessened physiological resistance include nephritis 
(in 10 per cent, of cases), alcoholism, cardiac disease, scurvy or gout; 
in other words peritonitis may be a terminal infection, fatal to reduced 
subjects. 

Atrium. — Compared with pleurisy and pericarditis, peritonitis is 
seldom primary. Though it may follow inflammation of every abdom- 
inal viscus, it is most commonly a secondary manifestation of intestinal 
disease (e.g., appendicitis), or of pelvic diseases in women, (a) Infec- 
tion may occur through the alimentary tract; appendicitis, bowel 
ulceration (typhoid, carcinomatous, tuberculous), bowel obstruction, 
perforation, traumatism and infarction may cause it. Gastric are less 
frequent than intestinal lesions and ulcer and cancer range first. (6) 
The internal female genitalia; it may result from gonorrhoea (Noeger- 
rath), extra-uterine pregnancy, puerperal infections and septic abortion ; 
peritoneal infection from diseases of the male genitalia is rare, (c) 



752 DISEASES OF THE PERITONEUM 

Liver and bile vessels; local or general peritonitis may result; perito- 
nitis is more common as a result of hepatic abscess and syphilis than of 
echinococcus, cancer, pylephlebitis, or cholecystitis, (d) Pancreas; 
acute pancreatitis, (e) Kidney and bladder; pyonephrosis, calculi, or 
ulcerations of the bladder. (/) Rarer causes are splenic affections, 
retroperitoneal adenopathies, spinal or costal caries, lesions of the 
thoracic duct, or the abdominal parietes, or extension through the 
diaphragm, (g) Metastatic peritonitis is not common, though it is 
observed in septicopyemia and in acute infections, (h) In children 
fcetal peritonitis has been observed by transplacental infection; in 
the new-born the umbilical vein may convey infection, though perito- 
nitis occurs in but 8 per cent, of fatal cord infections. It occurs more 
commonly through the lymphvessels of the cord; congenital syphilis 
may in this way cause peritonitis. 

Age and Sex. — Most cases occur between the ages of fifteen and 
forty and women are more often affected than men. 

Symptoms. — Symptoms are local and general. 

1. Local or Abdominal. — (a) Pain, the usual initial symptom, is 
almost invariable, is continuous, begins near the navel and remains 
greatest there; a causal gastric ulcer may produce pain in the back, 
salpingitis is attended with early pelvic pain, and appendicitis has its 
own initial localization, but the pain of diffuse peritonitis is felt at 
or below the navel, (b) Tenderness accompanies pain ; the tenderness 
is deep rather than superficial; tenderness and pain are very rarely 
absent and are caused by inflammation; at the operation or autopsy 
both the visceral and parietal investments are injected, reddened, lustre- 
less, covered with a thin film of fibrinous exudate which binds the in- 
testinal coils together; not infrequently the peritoneum is dotted with 
minute petechia, (c) The attitude is characteristic; the knees are 
drawn up and the head lifted to relieve tension and, in marked cases, 
to keep the bedclothes from contact with the abdomen, (d) Vomit- 
ing is reflex; it occurs early and greatly aggravates the pain; the 
vomitus contains food and later bile; it may be green (the vomitus 
herbaceus of the older writers), rarely dark brown or fsecal. It is 
accompanied by redness and dryness of the tongue, great thirst and 
singultus which is a sensory phrenic symptom; toward the fatal 
issue vomiting and singultus cease, (e) The abdomen on inspection and 
palpation is at first tense, retracted, and scaphoid, but later becomes tym- 
panitic from paresis of the inflamed intestinal coils (Stokes) and decom- 
position of their contents ; the diaphragm stands high and its movement 
is restricted; in some, especially muscular, subjects, the abdomen 
may be retracted throughout the course. Exploration by percussion 
may elicit dulness, which is usually due to serous, seropurulent, or 
perhaps serohemorrhagic exudation, which may be effused in small 
pockets between fresh adhesions or may fill the entire cavity, amounting 
to even 30 or 40 quarts and sometimes fluctuating to the hand; as 
a rule a tympanitic note prevails; in some cases dulness suggests the 
presence of fluid which, however, is not found on exploration; because 



ACUTE DIFFUSE PERITONITIS 753 

of adhesions, the fluid changes but little on change of posture. On 
auscultation a friction rub is sometimes heard (Beatty and Bright), 
chiefly over the liver. (/) Constipation is usual and results from in- 
flammatory infiltration of the intestine (Stokes); in the puerperal 
(streptococcic) and in pneumococcic peritonitides, diarrhoea is com- 
mon. 

2. General Symptoms. — (a) Shock is a conspicuous symptom. 
Collapse may occur early and directly from perforation or later from 
toxaemia. The pulse is frequent, hard, wiry, and averages about 120 
or more; later it becomes thready and runs to 140 or 170. The fades 
Hippocratica is pronounced, with its anxious expression, wrinkled, 
clammy, cyanotic, lead-colored skin, pointed nose, hollowed temples, 
and sunken eyes. The voice whispers (vox cholerica) to avoid move- 
ment of the diaphragm and the breathing is costal, shallow, difficult, 
and rapid, (b) Fever is usually but not always present. It may rise 
abruptly with a chill at the onset but follows no one type; it may be 
continuous or remittent, and there is usually elevation of temperature 
by rectum, even during collapse. The fever and pulse curves may 
run parallel in peritonitis with a slow course, (c) The lungs and 
heart are crowded upward by the abdominal distention. The apex- 
beat is high and further to the left as the heart lies more horizontally 
than in normal conditions, (d) The urine is scant from lessened ab- 
sorption and from cardiac weakness; albuminuria is frequent; indi- 
canuria is constant from increased putrefaction in the paretic bowel; 
dysuria is usual; tenesmus, due to involvement of the vesical serosa, 
is less common than retention. 

Course. — Though recovery is possible, the issue is fatal within two 
days in the rapidly fatal toxemic form in which there is only roughening 
of the peritoneum without exudation ; the slower cases rarely last more 
than five days. Consciousness is usually preserved to the end, though 
stupor or delirium occasionally intervenes ; the pulse becomes thready, 
the breathing shallow and sighing, the superficial temperature is low 
though rectal registration is high, and the patient succumbs to gradual 
or sudden cardiac failure from toxaemia. In exceptional cases death 
occurs within a few hours, or relative recovery results with encapsula- 
tion of pus. Treves found inhalation pneumonia in 17 per cent, of 
his cases and Tilger found serous pleurisy in 25 per cent.; of the 
latter, 63.3 per cent, was right-sided, 3.3 per cent, left-sided, and 33.3 
per cent, bilateral. 

Types. — (a) Peritonitis serosa usually follows the fibrinous form; 
the fluid is yellow or light green, its specific gravity is 1,015 or more, 
it contains 2 to 3 per cent, of albumin and flocculi of fibrin, epithelial 
cells, red cells, and leukocytes, (b) P. purulenta may occur in pockets 
or as a massive pyoperitoneum, amounting to 30 or 40 quarts, (c) 
P. putrida occurs in septicopyemia and puerperal fever, but espe- 
cially in perforating carcinoma; Obermeyer and Schnitzler have 
proven that foetid peritonitis may occur without perforation, (d) 
P. perforativa is characterized by two groups of symptoms, (i) those 

48 



754 DISEASES OF THE PERITONEUM 

of peritonitis and (ii) those of gas in the peritoneal sac (pneumoperi- 
toneum, pneumatosis peritonei) ; there is often (but not always) the 
initial subjective sense of perforation, sudden pain, collapse and 
retracted abdomen; in four to twelve hours diffuse peritonitis sets 
in, unless death occurs from the initial shock; free gas may obliterate 
the dulness of the liver and spleen though this also results from great 
tympanites without perforation; the liver dulness may be found only 
in the posterior axilla, but when the patient is turned on his left 
side the free gas entirely obscures it; the abdominal contents may be 
putrid or faecal, though when due to perforating gastric ulcer (q.v.) 
there is seldom any odor (Czerny). The diaphragm is pushed to 
its highest possible level; a succussion splash may be elicited, and the 
intestines may be compressed against the spine. It has been held 
that gas may develop in peritonitis without perforation through the 
action of the Bacillus pyogenes fcetidus and Bac. aerogenes encapsulatus 
but pneumoperitonitis without perforation is rare, (e) P. puerperalis, 
usually streptococcic, is described under septicopyemia ; it is char- 
acterized by moderate pain, enormous tympanites, diarrhoea, and the 
usual septic manifestations. (/) P. pneumococcica has been described 
by Sevestre, Moizard, Galliard, and Dieulafoy. Von Brunn has col- 
lected 72 cases, and these have been increased by Jensen to 106. 
It may be primary or secondary. Most cases occur in girls between 
three and twelve years old. The lower abdomen is especially involved, 
thereby often simulating appendicitis, which it also resembles in its 
abrupt onset, pain, fever, and vomiting; pneumococcic peritonitis is 
nearly always attended by early, continuous, foetid diarrhoea. It often 
points at the navel, through which a creamy, greenish pus may rupture. 
Sometimes it ends by crisis; an encysted pus sac often remains. The 
inflammation is usually purulent, and rarely serofibrinous. The pneu- 
mococcus may be found in the blood, (g) The streptococcic, colon, 
-and staphylococcic peritonitides are described under appendicitis. 

Diagnosis. — Peritonitis is usually diagnosticated with ease from the 
cause (appendicular, salpingitic, gastric ulcer, septic abortion), the 
febrile onset, pain, tenderness, vomiting, distention, effusion, and 
collapse. Puncture with an aspirating needle is dangerous. In certain 
cases only the fact of peritonitis can be established, perhaps even at 
operation, though the autopsy usually demonstrates a cause. 

Differentiation is necessary (a) from intestinal obstruction (q.v.); 
(b) from the pain of biliary or renal calculi; (c) from acute pancreatitis 
(q.v.); (d) from ruptured tubal pregnancy, in which the menstrual 
history, pelvic localization, and symptoms of acute anaemia and shock 
are present; (e) from ruptured abdominal aneurysm; or infarction of 
the superior mesenteric artery in which a cause for embolism, acute 
obstruction, and bloody vomiting or diarrhoea with later peritonitis 
are often distinctive; (/) from acute enterocolitis, which is attended 
by less pain and tenderness and by more diarrhceal colic, tenesmus, and 
collapse, due to dessication of the tissues and to toxaemia; (g) from 
hysteria (q.v.), which may simulate peritonitis, as it may resemble 



CHRONIC DIFFUSE PERITONITIS 755 

every other disease: the first cases seen by young practitioners may 
be very deceptive; if its presence is once suspected, the other stigmata 
are usually definitive, (h) The referred abdominal fain of thoracic 
disease (pleurisy and pneumonia) is not accompanied by tenderness, 
and is easily distinguished by examination of the chest, especially of 
its posterior parts. {%) Mild infections with much exudation may 
simulate ascites (q.v.). 

Treatment. — Surgical treatment alone is of any value. In most 
statistics the percentage of recoveries is not large; Koerte estimates 
it at 35 per cent., Haenel at 37 per cent., and Krogius (680 cases) at 
28.5 per cent. The author has seen, in Murphy's service, 35 out of 36 
consecutive cases of diffuse purulent peritonitis recover under operation, 
the last one being a case of streptococcic peritonitis ; Murphy institutes 
drainage, puts the patient in Fowler's semi-erect posture, and admin- 
isters continuously enemata of normal salt at low pressure. Had he 
not seen the cases, the author would accept no one's word for these 
remarkable results, which were obtained chiefly in patients apparently 
moribund. Deaver reports a series as large as Murphy's and Morton 
had twelve recoveries in fourteen operations. 

Palliative treatment is of little value, (a) The opium treatment only 
controls pain and though suffering must be relieved by drugs or opera- 
tion, the doses recommended by Alonzo Clark (more than 1,000 grains 
of opium in one week!) are now only of historical interest. Morphine, 
given hypodermatically, produces the best results, (b) The patient 
should have absolute rest, (c) Tait's method of saline purgation to 
increase osmosis, is productive of more harm than good, (d) Vomit- 
ing is treated as in acute gastritis ; the stomach should be washed out ; 
then all medication, food and water by mouth should be withheld, 
and given only by rectum, (e) Tympanites should be treated by the 
turpentine stupe, and by enemata containing tr. asafcetida ^i\], spts. 
chloroform 5j and spts. turpentine 5 SS - 



(B). CHRONIC DIFFUSE PERITONITIS. 

Aside from tuberculous peritonitis, chronic diffuse peritonitis is 
uncommon, (a) The serous or serohemorrhagic, form will be con- 
sidered under ascites; (b) the diffuse adhesive form results from acute 
peritonitis and from tuberculous peritonitis; in this form the peri- 
toneal sac is obliterated and at operation or necropsy the knife cuts 
directly into the intestine, (c) Chronic proliferative peritonitis may 
occur in peritoneal cancer or tuberculosis, chronic alcoholism, cir- 
rhosis of the liver, or cardiac disease. It may develop with or with- 
out adhesions, as a diffuse sclerosis of the peritoneum and as a 
subperitoneal proliferation. In its extreme forms it was described by 
Virchow (1885) as peritonitis deformans. The peritoneum is white, 
lustreless, and diffusely thickened, though in some places more than 
in others. The omentum is retracted upward, so that it lies as a hard, 



756 DISEASES OF THE PERITONEUM 

transverse roll above the navel, and the mesentery is indurated (mes- 
enteritis retrahens) as described under tuberculous peritonitis. As the 
mesentery retracts, it may gather the intestinal coils into a ball no 
larger than a child's head, lying centrally or to the right of the median 
line. Here and there may be found multilocular serous encapsula- 
tions, or there may be no serous exudation, at least when the case 
comes under observation. There may be palpable tumor-like thick- 
enings. The spleen, liver, stomach, csecum, or colon may be partic- 
ularly indurated. In some cases it is but part of a multiple cirrhosis 
(polyserositis, polyorrhomenitis), invading also the pleura and peri- 
cardium. Miliary fibromata, resembling miliary carcinosis or miliary 
tuberculosis, may sometimes form around parasitic ova or cholestearin 
crystals. 

(C). LOCALIZED PERITONITIS. 
I. Suppurative Forms. 

1. Subphrenic Abscess and Pyopneumothorax Subphrenicus. — 

Subphrenic suppuration was first diagnosticated by Barlow (1845), and 
was especially described by Leyden (1879). MaydFs monograph 
(1894) comprised 179 cases, upon which the following figures are 
based; sixty cases are described by Koerte (1903). 

Etiology. — (a) Gastric ulcer causes 19.5 per cent.; gastric cancer 
is less frequent, (b) Appendicitis causes 14 per cent.; (c) trauma, 
14 per cent.; (d) intestinal ulceration, 7.3 per cent.; (e) cholangitis 
and cholecystitis, 11 per cent.; echinococcus, 7.3 per cent.; liver 
abscess; (/) metastatic abscess, 6 per cent.; (g) perinephric abscess, 
6 per cent.; (h) occasionally, ulcerative lung lesions, 5 per cent.; 
(i) splenic infarct, abscess or echinococcus, diseases of the spine, ribs, 
pericardium or uterus are uncommon. 

Symptoms. — Pus is always present, is ensacculated beneath the 
diaphragm (pyothorax subphrenicus) and is associated in 26 per cent, 
with gas formation (pyopneumothorax subphrenicus). The subphrenic 
abscess is usually right-sided, is limited by the suspensory ligament of 
the liver and may be intra- or extraperitoneal; in the latter instance 
the abscess is most often appendicular or perinephric and lies well 
back in the abdomen. Cases with simple pus formation are often 
difficult to localize; their symptoms are those of sepsis with pain, 
tenderness, or dulness on the liver convexity, which suggest liver 
abscess. The retroperitoneal forms give most dulness posteriorly, 
but in intraperitoneal forms it is chiefly located anteriorly; swelling 
and oedema of the chest wall are unimportant but may occur without 
suppuration; the arrays may produce a subphrenic shadow. 

In pyopneumothorax subphrenicus there are signs "of a cavity be- 
neath the diaphragm, filled with gas and pus, pushing the diaphragm 
upward and simulating pyopneumothorax" (Leyden). (a) Tympany 
and absence of vesicular murmur and of vocal fremitus are found from 



ADHESIVE OR INDURATIVE FORMS 757 

the third rib downward, above which is the compressed lung, and 
below which is (b) the dulness of the liver whose exposed surface and 
edge, dislocated downward, are easily percussed and palpated. Some- 
times the tympany entirely covers the liver dulness. As in pneumo- 
thorax (c) succussion and, on change of posture, the clearly shifting 
line of dulness may be elicited, (d) Puncture evacuates gas and putrid 
pus; sometimes on a higher puncture serum is found in the pleura 
for pleurisy develops in 66 per cent, of the cases. The needle ascends 
during inspiration and descends during expiration, which is the con- 
verse of the findings in pleural exudation (Fuerbringer). If a manom- 
eter is attached to the exploring needle, a rise in the indicating 
column during inspiration and a fall during expiration denote a 
subphrenic lesion (Pfuhl). (e) The x-rays may show movement of 
the diaphragm and a shadow between it and the liver, but in three 
cases the writer found no respiratory excursion. (/) Perforation into 
the lungs occurs in 16 per cent, (more often in extra- than in intra- 
peritoneal forms), into the pleura in 19 per cent., and into the peri- 
cardium in 1 per cent. At the beginning, and until perforation, there 
is generally an entire absence of such thoracic symptoms as cough 
or sputum; this is of value in differentiation from true pyopneumo- 
thorax, (g) The history of the subphrenic pyopneumothorax is usually 
that of some abdominal lesion (v. Etiology). 

Treatment is surgical. In Maydl's series, 74 cases were operated 
on. Koerte's experience with 60 operations gives 66 per cent, of 
recoveries. 

2. Suppuration in the Lesser Peritoneum. — This may result from 
gastric or duodenal ulceration, acute pancreatitis, etc. Closure of the 
foramen of Winslow confines the pus; a tumor appears in the epi- 
gastric, umbilical or left hypochondriac region, bounded above by 
the stomach, which also in part covers it, below by the colon, and 
behind by the pancreas and retroperitoneal tissues. Its relations are 
like those of pancreatic cyst; variability in its size occurs when the 
stomach is filled with gas and fluid. When gas and pus co-exist the 
diaphragm and liver are pushed upward. Treatment is surgical. 

3. Other Forms. — The appendicular abscess has been described. 
The pelvic abscess occurs especially from tubal, but also from uterine 
and ovarian inflammation; it follows abortion, puerperal fever, gonor- 
rhoea, tuberculosis, and pneumococcic peritonitis in young girls. Other 
types are suppuration around the gall-bladder, colon, and sigmoid, 
and in other rare localizations. 



II. Adhesive or Indurative Forms. 

Local thickening or adhesions may occur over any abdominal viscus 
but especially over the spleen, next over the liver, and less commonly 
over the intestines; it may bind together two coils or form bands 
under which loops may become strangulated. 



758 DISEASES OF THE PERITONEUM 

Perisplenitis is most common over chronic malarial, leukemic, and 
pseudoleuksemic enlargements of the spleen and less frequent over 
acute splenic tumors. 

Perihepatitis may cover small areas of the liver like soldier's spots 
in the pericardium, or may engross its entire surface. General peri- 
hepatitis was described by Budd (1852), by Curschmann (1884), 
who called it the "icing liver" (Zuckergussleber), and by Fagge, Hale 
White, Nichols, A. O. J. Kelly and others. It is frequently associated 
with deforming proliferative peritonitis. Nichols describes it as a 
hyaline degeneration, hyaloserositis. Following Rolleston, there are 
apparently three groups of cases; (a) multiple serositis (polyorrho- 
menitis, Concato's disease); this borders closely on Pick's "pseudo- 
cirrhosis pericarditica." Kelly has assembled 27 cases in which 
perihepatitis was associated with adhesive pericarditis. (b) Arterioscler- 
osis and interstitial nephritis occurred in 86 per cent., in Hale White's 
series of 22 cases, (c) Other rarer factors are syphilis, tuberculosis, 
malignancy, and alcoholism. Its symptoms may be those of cirrhosis; 
it will be differentiated under ascites (y.i.). 



III. Chronic Hemorrhagic Peritonitis. 

This is a rare disease and was described first by Virchow, who 
likened it to pachymeningitis hemorrhagica. It occurs chiefly in the 
pelvis and is most often circumscribed. This pachyperitonitis is 
characterized by hemorrhagic inflammation; from the laminae of the 
resulting fresh connective tissue, which is deposited layer by layer, 
repeated fresh hemorrhages arise. 



(D). CARCINOMA OF THE PERITONEUM. 

Primary malignant growths of the peritoneum are endotheliomata, 
and are very rare. 

Cancer is most frequently secondary to cancer of the stomach, 
ovaries, intestines, pancreas, and liver. Histologically it is that of 
the primary growth. Its gross forms are (a) miliary carcinosis, re- 
sembling miliary tubercles; (b) vegetative; (c) ulcerative; (d) cystic 
and (e) infiltrative. The primary tumor may be quite latent clinically, 
so that the peritoneal complication is apparently primary. The 
secondary growths spread by contact, by the lymphatics, and by im- 
plantation of free particles. They may be felt in the omentum, mesen- 
tery, and Douglas' cut de sac and in some cases may be confused with 
tuberculous masses. The diagnosis is usually reached by the symp- 
toms and signs of the initial growth or by those of an ascites, which 
is serous, hemorrhagic, pseudochylous, or adipose; its progress is 
rapid and is attended by cachexia. Groups of cancer cells may be 
found in the aspirated fluid, and secondary cancer may develop at 



ASCITES 759 

the point of puncture. Differential features are tabulated under the 
next topic. 

(E). ASCITES. 

Ascites (hydroperitoneum) is a symptom and sometimes the chief 
symptom of various diseases. 

Etiology. — (a) It may result from stasis, of which the chief varieties 
are valvular and other cardiac lesions, pulmonary, mediastinal or 
pleural disease, and portal stasis, due to disease of the liver or of the 
portal vein. Stasis causes increased pressure in the portal system, 
followed by malnutrition of the vessels and pouring out of serum, (b) 
Hydremia or cachexia causes malnutrition and increased permeability 
of the vessel walls ; it occurs in amyloidosis, chronic nephritis, marantic 
conditions, profound anaemias, and occasionally in acute affections, 
(c) Inflammation, as simple, tuberculous, suppurative or cancerous 
peritonitis, may be an etiological factor, (d) Abdominal tumors, 
leuksemic spleen, etc., may cause ascites. In many cases more than 
one factor may operate; tuberculous peritonitis may complicate liver 
cirrhosis or ascites may be due to the hydremia of nephritis, accentu- 
ated by weakness of the heart. 

Symptoms. — 1. Inspection. — This shows a symmetrical enlargement 
of the abdomen, which, in the average case, presents rather more lateral 
than anterior bulging. The abdomen resembles that of a batrachian 
(ventre de batracien). The skin is pale, tense, striated, cedematous; 
the pouting navel and diastasis of the recti muscles are noted. A 
caput Medusa? may be noted in the cases of cirrhosis. Dilated veins 
over the ribs and sides of the upper abdomen indicate compression of 
the cava inferior. Sometimes the heart, beating upon the fluid, im- 
parts systolic waves to it. 

2. Palpation. — Fluctuation (ballottement) , due to the transmission 
of a fluid wave from side to side, is usually present but may be absent 
because of tense abdominal walls or great accumulation of fluid. 
Pseudofluctuation may be caused by accumulation of fluid other than 
ascitic, as intestinal contents, or by lax, obese abdominal walls; in 
the latter condition a third hand placed in the median line of the 
abdomen will break the deceptive wave, which is due to superficial 
or parietal vibration. Fluctuation is felt in ascites even where great 
tympany exists. In women the water-pilloiv fluctuation (Landau), 
may be elicited by vaginal examination, and Tripier remarks that the 
uterus seems remarkably movable. Thrusting palpation may disclose 
the outline of the liver, spleen, or possibly some neoplasm even through 
the abundant fluid: it is performed by placing the fingers vertically 
on the abdomen and suddenly thrusting them inward, thus anticipating 
any rigidity of the muscles and pushing aside the ascitic fluid. 

3. Percussion. — At least a pint to a quart (500 to 1,000 c.c.) of fluid 
must be present for clinical detection. With small effusions, the 
patient should be examined in the genupectoral position — which is 



760 DISEASES OF THE PERITONEUM 

the best method, according to Leube. Elevation of the buttocks 
causes scanty fluid to gravitate to the flanks where its presence is 
more easily demonstrated. Classically, the fluid in dependent parts 
gives dulness, and the supernatant intestines are located by tympany 
in the highest parts of the abdomen. These areas vary with change 
of position, always giving, in uncomplicated cases, tympany above and 
dulness below, in any posture the patient may assume. When the 
patient lies upon his back, the tympanitic area is central and elliptical. 
This rule is void when the mesentery is retracted and does not allow 
the gut to float, in which event there is dulness over the highest areas 
on light percussion, though tympany can be elicited on deep percus- 
sion over the same area; adhesions between the intestinal loops pre- 
vent shifting of the fluid; two lines of tympany in the flanks mark 
the ascending and descending colon; when the gut is adherent ante- 
riorily, there is permanent tympany in that location, and the author 
knows of an instance of ascites in which, ignoring this possibility as 
well as the physical signs, a physician perforated the intestines, 
though happily without unfavorable issue; immovable tympany in 
the flanks in ascites may be due to extensive adhesions of intestinal 
coils to the lateral abdominal parietes. Light percussion is employed 
in the determination of ascites, because heavy tapping elicits tympany 
from the adjacent or more deeply-situated intestine. 

A large quantity of free fluid may, in very rare instances, exist 
without dulness. The author has withdrawn two gallons of ascitic 
fluid from a patient in whom no dulness could be elicited in any position. 

(Edema of the subcutaneous tissues renders percussion of the 
abdomen difficult, as do fatty abdominal walls, fatty omentum, and 
fatty mesentery. The manometric pressure in the abdomen amounts 
to 20 to 40 mm. of mercury. 

Diagnosis.— Although ascites is usually one of the most easily 
demonstrable physical conditions, nevertheless many excellent clin- 
icians have mistaken it for other affections. Facal accumulations 
cause dulness in either flank, simulating fluid, but the history of the 
case, the immobility of the dulness, and the use of enemata or catharsis, 
preclude error. Large quantities of semifluid, faces in the ascending 
and descending colon may closely resemble free fluid; on thrusting 
palpation a splashing sound may be elicited over the colon, and 
Kuessner publishes a case in which a large quantity of fluid in the 
intestines was mistaken for ascites. Leube confused ascites with an 
enormously dilated stomach. Preperitoneal lipoma, hydronephrosis, 
hydatid cyst, pregnancy, dilated bladder, ovarian cyst and tympanites 
are frequently, though unnecessarily, sources of error. 

Rostan (1837) noted that tympany might be absent in ascites when 
the intestines contained little or no gas, a point sometimes forgotten 
in differentiation between ascites and ovarian cyst, the latter of which 
may also thrust itself in between the coils of gut and simulate ascites; 
ovarian cyst usually produces a central flatness with tympany in the 
flanks, and neither the dulness nor tympany shifts with change of pos- 



ASCITES 761 

ture. Adami has collected 42 cases of fatty tumor (fibrolipoma and 
myxolipoma) in which ascites is very closely simulated. 

Etiological Diagnosis. — 1. Stasis. — In cardiac disease the dyspnoea 
develops early, but that caused by ascites pressing upward on the 
diaphragm is a late symptom; swelling of the feet usually antedates 
the ascites, though Strumpell (1883) pointed out that pericarditis and 
valvular disease may exceptionally produce ascites without anasarca. 
It must be borne in mind that a marked ascites may crowd the heart 
upward and outward. The liver is peculiarly an etiological factor in 
ascites (see Differential Chart under Liver Diseases). Portal 
ascites commences almost invariably in the peritoneum; the legs swell 
secondarily from pressure on the vena cava inferior or from cardiac 
weakness due to great ascites (Giovanni); the legs may swell dis- 
proportionately, cicatrices may involve the portal vein and cava sim- 
ultaneously at the notch in the posterior surface of liver, and finally 
the legs may swell first. In some cases the ascitic fluid may lie between 
the diaphragm and the liver, which latter is then pushed downward 
and may appear large though it is merely dislocated. An attempt 
should be made to exclude perihepatitis, which, according to Fagge, 
causes one death to every five fatal cases of cirrhosis, and is more 
apt to be attended by albuminuria (see Table given below). 

2. Hydraemia. (Cachexia, Increased Vascular Permeability). — In renal 
disease the eyelids often become cedematous before other symptoms 
develop and the nephritic ascites is seldom great unless the liver and 
heart are involved. Cachectic ascites is not uncommon in leukaemia 
and kindred affections. Slight serous effusions occurring in acute infec- 
tious diseases in children may come under this title. The author has 
seen three instances of ascites in typhoid convalescence. 

3. Peritonitis. — The specific gravity and the percentage of albumin 
in the fluid are important factors in differentiating between exudate 
and transudate. Three divisions are distinguished: (a) a specific 
gravity of 1,010 or lower indicates a cachectic transudate, e.g., in 
nephritis with less than 1 per cent, albumin. A very low specific 
gravity and percentage of albumin occurs in amyloidosis, (b) A 
hypostatic transudate has a specific gravity which ranges between 
1,010 and 1,014, and has between 1 and 3 per cent, of albumin, (c) 
An exudate has a specific gravity of more than 1,015 (or 1,018) and 
the albumin reaches 4 to 6 per cent. The lower strata are heavier, 
and the specific gravity should be measured several times during the 
paracentesis. When there is less than 1 per cent, of albumin, no 
disease of the peritoneum or portal vein exists. Reuss' formula en- 
ables us to compute the albumin percentage from the specific gravity. 
It is subject to an error of less than f of 1 per cent.; the percentage 
of albumin = f (specific gravity minus 1,000) minus 2.8. A specific 
gravity of 1,017 to 1,020 positively indicates an exudate. There are 
certain exceptions to this rule, and certain confusions may arise; 
thus an ascites due to a carcinoma in the liver substance has a low 
specific gravity and albumin is present to 1 or 2 per cent. If the 



762 DISEASES OF THE PERITONEUM 

carcinoma spread to the peritoneum (carcinomatous peritonitis), the 
specific gravity rises and 5 per cent, of albumin, or more, is found. 
An ascites due to nephritis has a low specific gravity but the figures 
rise when stasis due to weak heart or intercurrent inflammation devel- 
ops. In many cases of simple transudation (ascites and hydrothorax), 
the characters of an exudate may develop, due to the long-continued 
irritation of the serosa. 

Ascitic fluid always contains the constituents of the blood — albumin, 
globulin, urea, xanthin, hypoxanthin, guanin, uric acid, sugar, etc. 
(a) Ascitic fluid due to stasis is clear yellow or yellow-green, opales- 
cent, and alkaline, and microscopically contains some lymph cells, 
erythrocytes, and peritoneal endothelium. (b) Exudates show a 
microscopic picture varying with the cause; fibrin threads, pus, blood, 
adipose, chylous or chyliform fluid, intestinal contents, cancer cells, 
tubercle bacilli, diplococci or pyogenic organisms, may be found. In 
exudates are found the polymorphonuclear leukocytes and some 
erythrocytes; lymphocytes and red cells are detected in transudates 
and tuberculous exudates (see Pleurisy) ; the fluid must be examined 
at once or formalin should be added for the cells readily degenerate 
and shrink. Rieder,Dock and others describe cells in carcinomatous 
peritonitis in which asymmetrical karyokinetic figures appeared. 
Quincke states that red disks, lymph cells, and peritoneal endothelium 
are found in every ascites. 

Primavera differentiated between transudates and exudates by 
means of glacial acetic acid; a single drop will leave a white cloud 
as it falls to the bottom of a vessel containing an exudate, while its 
addition to transudates gives no reaction. 

The French authors, especially, assert the existence of a primary 
ascites due to cold, excessive catharsis, drinking freely of water, 
suppression of menses or checking of hemorrhoidal bleeding. This 
so-called "essential" ascites is usually a chronic serous or tuberculous 
peritonitis. 

Differentiation Between Serous and Tuberculous Peritonitis. — Henoch 
believes that chronic serous peritonitis occurs in children though West 
and Courtois-Suffit think such affections are tuberculous. In tuber- 
culous peritonitis (q.v.) there are usually temperature, emaciation, 
and bacilli in the exudate. According to Tepret and Vierordt, chronic 
nontuberculous peritonitis occurs especially in women, the causes of 
which are Bright's disease, trauma, portal stasis, alcoholism, and 
heart affections. The ascitic forms of nontuberculous peritonitis 
may pass into the membranous or adhesive variety (peritonitis de- 
formans or pachyperitonitis). The diagnosis of simple nontuberculous 
peritonitis is most difficult to establish, even at autopsy, and the diag- 
nosis in doubtful cases of a tuberculous peritonitis is by far more 
frequently justified. 

Differentiation Between Tuberculous Peritonitis and Ascites. — 
Mechanical (portal) ascites is accompanied by other circulatory dis- 
turbances, as splenic tumor, piles, or caput Medusae. The spleen is 



ASCITES 763 

rarely enlarged in tuberculous peritonitis. The specific gravity and 
percentage of albumin are almost final in determining between peri- 
tonitis and ascites. The fluid is generally clear in ascites and usually 
cloudy in peritonitis. Pain and fever usually indicate encapsulation. 
The liver is small in the terminal stage of atrophic cirrhosis, which 
is also marked by various urinary changes; these are evidences of 
incomplete discharge of the hepatic function. In tuberculous peri- 
tonitis, the hydrops ascites saccatus gives an irregular form to the 
abdomen from meteorism produced by adhesions and from irregular 
nodules sometimes simulating carcinoma : it was described by Hippoc- 
rates. Free tuberculous exudations differ according to Thomayer, 
from simple ascites in that the tympany in tuberculous forms is often 
right-sided, due to retraction of the mesentery (mesenteritis retrahens) 
to the right side, carrying with it the small intestine. Mesenteritis 
retrahens is usually, either tuberculous or carcinomatous, but may 
sometimes be due to simple deforming peritonitis. The author recalls 
several instances in which right-sided tuberculous masses pushed to 
the left both the tympany and the fluid. Hemorrhagic ascitic fluid 
occurs frequently in tuberculous peritonitis, and rarely, if ever, in 
cirrhotic transudate. 

The "apparent tumors" (Bamberger) of tuberculous peritonitis are 
always suggestive where the nature of an ascites is in question. In 
two instances observed personally, the omentum was so retracted and 
so peculiarly adherent to the normal liver as to resemble most closely 
the edge of an enlarged cirrhotic liver. Intestinal or pulmonary 
tuberculosis, adhesive pleuritis, and meteorism from intestinal adhe- 
sions, or an irregular form of the abdomen with a "doughy" feel on 
palpation, indicate tuberculous peritonitis. A good working rule is 
that a peritoneal exudate is tuberculous, when cancer, sarcoma, and 
trauma can be excluded. Exploratory incision is often the only direct 
route to diagnosis and appropriate therapy. In the case of Heidenrich, 
in which the fluid was encapsulated, each of about 20 separate sacs 
was filled with fluid differing from that found in the others; in one 
was clear serum; in another paler fluid; in others, the effusion was 
brown, purulent, thick, or sanguinolent. 

Nichols, in an excellent monograph ("A Somewhat Rare Form of 
Chronic Inflammation of the Serous Membranes [Multiple Progressive 
Hyaloserositis]," Royal Victoria Hospital Reports, vol. i, No. 3) 
gives a differential table, presented on the following page. 

4. Tumors. — Tumors, other than peritoneal, may cause ascites. 
Uterine fibromata produce hydroperitoneum, which is not usually 
great, is lemon-colored, and but rarely sanguineous. There is no 
relation between the size of the tumor and the amount of fluid tran- 
suded, because very small uterine myofibromata may excite consider- 
able peritoneal effusion. There is, nevertheless, a direct relation 
between the malignancy of the tumor and the amount of the fluid 
found (Terillon). As a general statement, ascites is infrequent in 
uterine tumors (Cruveilhier) but when observed is most common in 



764 



DISEASES OF THE PERITONEUM 



"Zuckerguss- 

leber"; chronic 

perihepatitis. 



Atrophic cirrho- 
sis of liver. 



Chronic tuber- 
cular peritonitis. 



Carcinoma of 
peritoneum. 



Age. 

Sex. 

Previous history. 

Alcoholism. 

Syphilis. 
Heredity. 

Incidence. 

Chronicity. 
Fever. 

Pain. 
Digestive. 



Occurs about mid- 
dle life or later. 



Oftenest about 
middle age. 



Commonest be- Occurs late in life. 

tween ages of 20 
• and 40. 



Both sexes equally IMore frequent 



liable 



males. 



in Predominates in 
females. 



More frequent in fe- 
males. 



digest 
dist 



isturbance. 



Ascites. 



Anasarca. 
Jaundice. 

Liver. 



Spleen. 
Omentum. 



Often a history of I History of alco- Often a chronic In some cases a his- 
acute pericarditis holism, syphilis cough, diarrhoea, tory of cancerjof 
or perihepatitis, or digestive dis- or genital tuber- stomach or ovaries. 
turbances. I culosis. 



No influence. 



No influence. 
No influence. 



Frequently 
ent. 

Occasionally. 
Unimportant. 



pres- Unimportant. 



Acute becoming Insidious, 
chronic or insid- 
ious from first. 



Unimportant. 



Unimportant. Unimportant. 

May be family Unimportant, 
taint. 

Onset may be Insidious, 
acute or insidious. 



May last for years. Prolonged. 



Cases last for 2-10- 
16 years. 

Generally absent' May be afebrile; Usually slight; 

except during ex- when present is often absent, 
acerbation or some slight, 
complication. 



Indefinite and 
trifling. 

Trifling or none. 



Trifling. 



Apt to be trouble- 
some. 



Constant; dyspep- Fairly common, 
sia, nausea, vom- 
iting, gastric hem- 
orrhage, melaena. 



Constant. 



Constant fand ex- 
treme; nutrition 
long maintained 
— Osier's case tap- 
ped 121 times; 
may resemble per- 
itonitis, albumin 3 
per cent., fibrin. 



Constant but slight. Relatively slight. Trifling. 



Never extreme, 
may be absent, 
may be hemor- 
rhagic. 



Absent in pure 
cases. 

Not cirrhotic; at 
first enlarged, 
then small; 
smooth. 



Occurs in 27 per 
cent, of cases. 



jMay occur ex- 
ceptionally. 



Cirrhotic; at first Often enlarged, 
enlarged, then 
small and warty.': 



Gradual 
ment. 



enlarge- Gradual 
ment. 



Thickened and con- Normal, 
tracted. 



enlarge- Nothing special. 
Often matted up. 



Fairly rapid course. 



Rarely absent; due 
to complication. 



Variable. 
Often marked. 



Moderate grade; 
may be hemor- 
rhagic or pseudo- 
chylous. 



Slight. 

Common when fiver 
is enlarged. 

May be enlarged, 

with nodules. 



Nothing special. 
Often matted up. 



adenomyoma (Freund). It is more often seen in papillomatous cysts; 
in glandular cysts whose walls rupture by fatty degeneration and pour 
out their contents into the abdominal cavity, serum is secreted by the 
peritoneal surface because of the irritation, even though the ruptured 
cyst be very small (Quenu). The fluid in cysts contains more solids 
(60 to 50 pro mille) than does the ascites of renal disease (25 pro 
mille, Mehu). Ascites is most often observed in solid ovarian tumors. 
In an ovarian sarcoma successfully removed by operation, an ascites 



CHYLOUS AND ADIPOSE ASCITES 765 

existed whose specific gravity was 1,024; the case recovered and 
remains well after nine years. 

Treatment. — The treatment of ascites varies with its cause, for 
which reference should be made to valvular heart disease, atrophic 
cirrhosis, tuberculous peritonitis, and nephritis. 

Paracentesis in peritoneal carcinoma and chylous ascites (v.i.) 
hastens the issue. Hale White asserts that cases of cirrhosis survive 
but few punctures, while cases of perihepatitis may be punctured 
more than 200 times. Lecanu reports a case of ascites in which 885 
tappings were performed in fifteen years. In puncture, surgical anti- 
sepsis is most necessary, for reduced subjects are easily infected. The 
bladder should be emptied by catheterization. The trochar should 
be introduced in the linea alba to avoid injury to the bloodvessels. 
It should be pushed carefully and is felt to penetrate the parietal 
peritoneum by the sense of something giving away. A dull-pointed 
probe should be sterilized, with which to push back the omentum 
if it should prolapse against the canula. The fluid should be evacuated 
slowly to obviate collapse which may result from dilatation of the 
abdominal veins, if they are suddenly relieved of the pressure of the 
effusion. A cat-o '-nine-tails bandage may be applied as the tapping 
progresses, to compress the abdominal contents. 



Chylous and Adipose Ascites. 

The peritoneal cavity, much more frequently than any other serous 
sac, is the seat of those unusual exudates and transudates known as 
chylous, chyliform, lactiform, oily, or adipose ascites. The first au- 
thentic case is Poncy's (1699). During the last two centuries the litera- 
ture gives about 200 cases. Seven have come under the author's 
observation. 

Much confusion has arisen from inaccurate nomenclature. Chylous 
ascites properly designates an effusion of chyle. Adipose ascites 
contains a large percentage of fat with no chylous admixture. Some 
authors use the terms "adipose," and "chyliform" interchangeably. 
Boulengier prefers the term "chyliform" and "lactiform" to "chy- 
lous" on the ground that the fluid is rarely chyle. Chyliform ascites 
is a chyle-like fluid in which lymph or chyle is mixed with exudates 
or transudates. 

1. Chylous Ascites. — Straus' case is the clearest example, in which 
chemically typical chyle was extravasated through two fistula?. In- 
gested butter was recognized in the fluid withdrawn by paracentesis. 
Senator's latest case gave similar results with the administration of 
olive oil. Chylous ascites contains sugar, which is said to be diagnostic 
when diabetes is excluded. Sugar when primarily present may dis- 
appear later (Whitla). Its presence is very rare and very suggestive; 
it has been detected not more than two dozen times. Of late many 
clinicians discount the importance of the presence of sugar as a diag- 



766 DISEASES OF THE PERITONEUM 

nostic test; Bock found sugar (0.04 to 0.07 per cent.) in all cases of 
hydrops, and Eichhorst in ten out of seventeen cases of pleural exudate. 
A small amount of fat (0.9 per cent.) indicates chyle. Chylous ascites 
is rich in solids, mineral salts, and albumin. Albumin and fat occur 
in small punctiform granules, susceptible of chemical differentiation. 
The escape of chyle may occur through a visible rupture or by transu- 
dation through the walls of the chyle vessels ; among the most frequent 
causes of lymph or chyle obstruction are compression of the thoracic 
duct or lymph system by glands, neoplasms, peritonitis, occlusion of 
left subclavian vein, pressure efforts, lifting or coughing, filarial 
disease, or occlusion of the thoracic duct. Rupture may occur in any 
part of the lymphatic system; in the thoracic duct, receptaculum, 
lacteal vessels, lymph glands, and chylous cysts. Chyle may extra v- 
asate into a serous effusion by mural alteration of the lymphatic 
vessels. 

2. Adipose or Chyliform Ascites. — Adipose ascites is characterized 
by the absence of sugar and a higher percentage of fat. The degree 
of opacity is no index of the amount of fat, because turbidity may be 
due to emulsionized albumin. Fat is found in most cases; its greatest 
amount is 5.25 per cent. (Schmidt), and in one of the author's cases 
6.5 per cent. The granules of albumin and fat are much coarser in 
adipose than in chylous ascites. Hydropic and fatty carcinoma cells 
may, if numerous, cause a creamy layer, and their microscopic detec- 
tion^favors the diagnosis of hydrops adiposus. Red blood disks may 
occur, also fibrin, filaria, casein, mucin, sodium alkali albuminate, 
bile, acetone, hydropsin. peptone, lecithin, cholestearin, fibrinogen, 
diastatic ferments, urea, and various inorganic compounds. Among 
the numerous etiological conditions are tuberculosis of the peritoneum 
and glands; carcinoma of the glands, peritoneum, and lymph vessels; 
chronic peritonitis; liver cirrhosis, heart disease, and sarcoma of the 
omentum or mesentery. 

Diagnosis. — A diagnosis has never been made prior to puncture, 
except in Morton's early case. The local signs and symptoms do not 
differ from those of serous ascites. It is probable that some cases 
diagnosed as the vulgar ascites, healing without treatment, are in- 
stances of chylous hydrops; this explains the increasing frequency of 
these affections. It is not easy to differentiate between chylous and 
adipose effusions, even at necropsy. 

Prognosis. — About 90 per cent, of both types die. Continuous 
chylous fistula? are always fatal. The immediate prognosis is seem- 
ingly more favorable in the adipose form. 

Treatment. — Surgical interference is chiefly indicated in tuberculous 
peritonitis. Paracentesis should be avoided as much as possible for 
it is weakening, and precipitates the fatal issue. 



SECTION V. 



DISEASES OF THE KIDNEY. 



(A). ACUTE NEPHRITIS. 

Etiology. — (a) Acute nephritis may result from infections. The 
scarlatinal nephritis (q.v.) is the most frequent type, and develops 
during the third week after desquamation. It also occurs in diph- 
theria, at the height of the disease; it is found in a large percentage 
of cases of acute enterocolitis in children ; it may result from malaria, 
variola, sepsis, ulcerative endocarditis, or pneumonia; there is scarcely 
an infection in which acute nephritis may not occasionally develop, 
as typhoid, typhus, measles, tonsillitis, or epidemic meningitis; it is 
rare in German measles, varicella, or purpura. It may develop in 
tuberculosis and syphilis. Infections operate (i) more often by their 
toxins than (ii) by the causal microbe, though the typhoid bacillus, 
recurrens spirillum, pneumococcus, streptococcus, and others, have 
been found in the kidneys and urine; (hi) in some instances (nephritis 
hsemoglobinurica) hemolysins develop and apparently cause acute 
nephritis, (b) Toxic substances, taken internally or applied to the 
skin, may induce acute nephritis; as turpentine, salicylic compounds, 
carbolic acid, potassium chlorate, cantharides, and kindred substances, 
(c) Exposure to cold and dampness (with alcoholism) is frequently the 
sole apparent cause, though its mechanism is obscure; possibly it 
lessens the tissue resistance or acts as a hemolysin, as in the heruo- 
globinuric type, (d) Skin diseases, burns, eczema, and psoriasis, may 
be etiological factors, either by lessening the skin functions, by pro- 
ducing hemolysins, or by too active medical treatment (nephritis 
medicinalis). (e) Pregnancy (v.i.) may result in nephritis. (/) The 
cause is often obscure; chronic B right's disease, cardiac affections. 

767 



768 DISEASES OF THE KIDNEY 

and the dyscrasise, predispose to acute nephritis, (g) Acute nephritis 
may occur independently of any known cause; this primary form 
may be epidemic. 

Pathology. — Ch-oss changes may not be apparent in mild cases, 
though in some the kidneys are swollen from marked interstitial 
exudation, and are dark and heavy. In other cases the kidney is 
yellow-white, and perhaps mottled from small hemorrhages. The 
cedematous capsule strips readily and the cut section drips blood. 
On section the cortex is swollen and granular, and its striations are 
blurred and pale in contrast with the dusky medulla; the glomeruli 
are frequently visible as red or later as yellow dots. Without the 
microscope, lesser degrees of acute nephritis may be confused with 
fatty or parenchymatous degeneration. Microscopic changes are 
usually diffuse, (a) Glomerular changes. Glomerulonephritis, espe- 
cially described by Klebs, is caused by toxins reaching the tufts through 
the blood current. It is best exemplified by the scarlatinal form (q.v.). 
The glomerular capillaries show infiltration with leukocytes, an albu- 
minous or cellular exudate escapes into the capsule, and the epithelium 
of Bowman's capsule degenerates, desquamates, and later proliferates; 
in some cases numbers of red disks escape with the serum and leuko- 
cytes, (b) Tubular changes. Cloudy swelling, hyaline and fatty 
degeneration occurring especially in the cortex, may be difficult to 
differentiate from febrile and other degenerations, though interstitial 
exudation occurs in every case of nephritis. In severe cases some cells 
necrose entirely and desquamate; of this the diphtheritic form is the 
best type. The swelling in and around the convoluted tubules is one 
cause of the kidney enlargement, (c) Vascular and interstitial changes 
are essential to the pathological diagnosis and are more focal than 
diffuse. Serum exudes into the connective tissue, tufts, and tubules, 
and coagulates in them ; it is probably the cause of the casts ; leuko- 
cytes escape into the parenchyma and interstitium, and in some cases 
red cells also (hemorrhagic nephritis). Councilman describes Unna's 
plasma cells, which he thinks are conveyed to the kidney from the 
spleen and marrow. 

Symptoms. — The onset may be sudden, especially in cases following 
exposure. In other cases it develops gradually in the course or con- 
valescence of the causal infection as scarlatina, diphtheria, etc. In 
many cases it may be unrecognized unless frequent analyses of the 
urine are made, or until ursemic symptoms develop. 

1. Urinary Findings. — (a) The urine is decreased to ten or twelve 
ounces (a few hundred c.c.) or in severe cases is suppressed; this is 
due to glomerulitis or stoppage of the tubules by coagulated albumin 
and desquamated epithelium; the decrease usually runs parallel with 
the intensity of inflammation and hydrops. During convalescence the 
urine becomes abundant and clear, (b) Its color may range from that 
of febrile urine to a dark smoky tinge; it is seldom red or actually 
bloody; in the hsemoglobinuric form it is chocolate-colored, (c) The 
specific gravity averages 1,025 to 1,030 and (d) the reaction is acid. 



ACUTE NEPHRITIS 



769 



(e) Albuminuria is almost invariable; the albumin amounts to J to 
1 per cent, and one to two drams (5 to 8 gm.) daily. There is serum 
albumin, considerable quantities of globulin, and if there are many 
cells as in tubular nephritis, nucleo-albumin. The author has seen six 
fatal cases of acute diffuse nephritis, confirmed by autopsy, in which 



,\ 



Fig. 45. 



Hi 



3 




Casts. 1-4, amyloid; 5, cast, epithelial in its upper, and granular in its lower, part. 

there was no albuminuria. Similar cases are reported by Quirolo, 
Henoch, Senator, Fermi, Sanne, and others. (/) Urea is decreased 
even to -J its normal quantity, as are also the chlorides and phosphates; 
the uric acid remains normal, and the xanthin (alloxur) bases may be 
increased; for the molecular constitution of the blood and cryoscopy, 
see Chronic Nephritis, (g) The sediment in mild acute tubular neph- 

Fig. 46. 



tz\ 






-•■■*•'. Oi' 
O 0,0. ■■ 



Urinary casts; 1, hyaline, with fat droplets and cells ; 2, hyaline, with leukocytes ; 3, cast with 

fat droplets. 

ritis consists of many epithelial cells, some red and white corpuscles, 
and hyaline casts, with crystals of oxalate of lime and uric acid, and 
sometimes haemoglobin granules, which may be also found as free 
granules. In diffuse glomerular nephritis there are almost always 
red cells, mono- and polynuclear leukocytes, epithelium, fatty, hyaline 
and granular casts, granules of fat and often of haemoglobin, uric and 

49 



770 DISEASES OF THE KIDNEY 

calcium oxalate crystals, and sometimes various micrococci. Senator 
maintains that the leukocytes from the kidney are mononuclear. 
Waxy and epithelial casts are found only in the severest types. Blood 
and casts may appear before and may also outlast the albuminuria. 
The significance of casts (cylindruria) will be considered under chronic 
parenchymatous nephritis. 

2. Hydrops (Anasarca). — This is often the first symptom to attract 
attention, (a) It occurs about the eyes early in the morning and later 
in the day in other parts, as the limbs and external genitalia. As the 
process advances it may become general, (b) It changes its location 
readily, and with ancemia gives a rather characteristic fades, (c) 
Anasarca occurs most commonly in cases due to scarlatina and ex- 
posure, rather less commonly in those following pregnancy, malaria, 
alcoholism, and skin diseases, and seldom in those developing in sepsis, 
pneumonia, typhoid, or diphtheria., (d) It is caused by inflammation 
of the skin vessels, is identical with the inflammation in the glomerular 
vessels, and is nearly always associated with glomerulitis. (e) Iden- 
tical changes may occur in the serous sacs (pleura, pericardium, or, 
far less often, peritoneum, meninges, and joints), mucous membranes 
(glottis or intestinal tract), or viscera (pulmonary or cerebral oedema). 
(/) It parallels the intensity of the nephritis and the decrease of urine. 

3. Anaemia. — Anaemia is often an early symptom and with the dropsy 
is almost suggestive of acute nephritis. The red cells and haemoglobin 
are reduced, the specific gravity of the serum is lowered, and the 
freezing point is raised (v. Chronic Nephritis). 

4. Cardio- Vascular Symptoms. — The right heart may become di- 
lated. Hypertrophy of the left ventricle is very uncommon, though it 
was observed by Riegel and Leube within ten days of the beginning 
of the disease. The pulse is usually slow and tense; the sphygmogram 
shows increase of the tidal and decrease of the dicrotic wave, and the 
sphygmomanometer shows the blood tension increased even to 180 or 
200 mm. ; these phenomena are due probably to vascular contraction 
induced by metabolic products retained in the blood. The second 
aortic tone may become accentuated, and, if heart fatigue develops, 
the gallop-rhythm is heard. 

5. Temperature. — Fever and rigors are exceptional. 

6. Pain. — Occasionally there may be pain and tenderness in the 
back, frequent and painful urination, emaciation, and epistaxis. Con- 
stipation is the rule. The skin is generally dry. 

Diagnosis. — The urinary findings are characteristic; albuminuria 
(q.v.) may result from other causes, as fever, amyloidosis, or stasis; 
casts, leukocytes, epithelia, and even red cells, may also occur in chronic 
nephritis, but the history and evolution determine the diagnosis (y.i. 
Differential Table of Diffuse Diseases of the Kidney) ; cases 
without urinary findings are extremely rare. The greatest danger lies 
in the diagnosis of an acute nephritis, when the condition is only an 
acute exacerbation of a chronic process; fully half of the so-called idio- 
pathic acute cases which the author has seen belong to this category. 



ACUTE NEPHRITIS 111 

In renal hematuria the urine contains no casts (save perhaps red cell 
casts), few leukocytes, and practically no epithelia; there is no ana- 
sarca; the urine is clear at one time and is laden with blood at another. 
Anasarca (v.s.) occurs in certain types only and in various cachectic 
states. 

Diagnosis of Types. — (a) The kidney of pregnancy usually develops 
in the last half of gestation, and infrequently before the third month. 
Its pathogenesis is yet vigorously disputed, though toxaemia due to the 
double task imposed upon the maternal kidneys seems to be the most 
probable cause. It has been suggested that decreased antitoxic activity 
of the thyroid gland is a causal factor. The placenta is thought by 
some to elaborate toxins (syncytiolysins). The urine is decreased, pale, 
and of low specific gravity; it contains much albumin and not much 
sediment, though red and white cells, lymphocytes, fatty epithelia, 
and sometimes casts, are found. The attendant anasarca, like that of 
stasis, develops from below upward. When retinitis develops its 
prognosis is more favorable than it is in other nephritides. The con- 
vulsive seizures (eclampsia) are generally uraemic, though Ingerslev 
collected 106 cases in which there was neither clinical albuminuria nor 
renal alteration at necropsy. Fehling remarks on the slight anatomical 
changes in the kidney and on the fact that but 5 per cent, of pregnant 
patients having nephritis develop eclampsia. The exact explanation 
of the convulsions remains obscure, though it seems that the brain 
centres during gestation are unduly susceptible to irritation. The 
embolism of placental cells in the brain or lungs (Schmorl) is con- 
sidered by some rather as a result than a cause of eclampsia. Zweifel 
maintains that the oxydation of the albumins is decreased, the nitrogen 
output is decreased, the ammonia (as in diabetic coma) is increased, 
and that sarcolactic acid is found in the blood and urine. The maternal 
mortality is 25 to 30 per cent., and that of the child over 50 per cent. 
Very few cases develop chronic nephritis, (b) The cholera nephritis 
is parenchymatous and chiefly tubular. Various factors are operative, 
as toxaemia, arterial anaemia, venous hyperemia, and heart weakness. 
By some it is considered renal ischaemia rather than nephritis. The 
urea, chlorides, calcium and magnesium salts are decreased, and 
much indican, aromatic sulphates, acetone, and ammonia, are found. 
The anuria may last three or even fifteen days, (c) Hamoglobinuric 
nephritis is probably due to hemolysins, which disorganize the blood 
and irritate the kidneys by the haemoglobin thus set free. It is found 
in burns, acute infections (typhoid, pernicious malaria, scarlatina, 
yellow fever, Winckel's disease of the new-born), exposure, haemo- 
globin eemia, and various drug poisonings, notably that of chlorate of 
potash. Haemoglobinuria, red disks in the urine, casts, leukocytes, 
epithelial cells, and abundant albuminuria, are indicative of haemo- 
globinuric nephritis, (d) Acute recurrent (chiefly hemorrhagic) nephritis 
is uncommon. 

Prognosis. — The prognosis of acute nephritis is always dubious. 
The following factors are important: (a) Recovery is usual in light 



772 DISEASES OF THE KIDNEY 

forms not involving the glomeruli. Atypical forms are generally 
favorable, (b) The prognosis varies according to the causal affection; 
the scarlatinal type has a mortality of 33 per cent.; the virulence of 
the epidemic is an important factor, as are also heart complications, 
(c) Complications may affect the prognosis, as (i) intercurrent inflam- 
mations, such as pneumonia, pleuritis, pericarditis, or erysipelas; (ii) 
oedema of the pharynx, larynx, lungs, or serous sacs; and (hi) urosmia, 
which will be fully covered under chronic interstitial nephritis ; uraemia 
is more often an adult than an infantile, and a later rather than an early, 
complication, though convulsions may be its first symptom; headache, 
delirium, dyspnoea, convulsions, coma, and vomiting, are among the 
salient signs of uraemia. 

Course. — The course is seldom fatal within a few days. In general 
there are more recoveries than deaths. The average duration is less 
than two weeks, though one or two years may elapse before recovery. 
Convalescence is usually complete, though gradual transition into 
chronic nephritis sometimes results. 

Treatment. — Most of the points mentioned will be considered more 
fully in the treatment of chronic nephritis, (a) Prophylaxis is of 
limited value. Drugs which irritate the kidneys should be carefully 
avoided in acute infections or in pregnancy. In fevers, with or without 
albuminuria, water should be given freely by mouth or by enema; 
hydrotherapy is prophylactic, save in scarlatina, when all prevention is 
seemingly futile and cold baths are contra-indicated. Induction of 
labor is indicated in severe cases in pregnancy, (b) The diet should 
be regulated. Milk is a moderate diuretic, is non-irritant, and contains 
little or no extractives or salt. It should be given as in typhoid (q.v.). 
Thoroughly cooked carbohydrates, as gruels, make a good combina- 
tion with it. Broths and beef-tea are to be avoided, and meats should 
be administered only late in convalescence. Alcohol is contra-indicated, 
save as exceptionally necessitated by the causal disease, (c) Abso- 
lute rest in bed is imperative; rest with the body covered, protects the 
skin and spares the products of the tissue waste, which are eliminated 
by the kidneys; the patient should lie between flannel blankets and 
should be dressed in flannel nightgowns. . (d) There is no drug which 
affects the nephritis; tannin and ergotin (of each five grains three 
times daily) seem to restrict renal hemorrhage. Salt should be largely 
withheld, because it increases albuminuria and oedema (see Treat- 
ment of Chronic Nephritis), (e) The best diuretics are water and 
milk, which flush out detritus from the kidneys. The alkaline charged 
waters seem to search out waste substances in the tissues and facilitate 
their removal by the kidney (but excessive quantities are often given) ; 
potassium citrate and sodium benzoate are said to have the same 
effect ; the citrate may be given in doses of half a dram with sweetened 
weak lemonade. Sweet spirits of nitre 5 SS to 5j> q-i-d., is diuretic 
and also dilates the bloodvessels. All stronger diuretics are to be 
avoided. (/) The skin should receive consideration. Warm baths are 
diuretic and stimulate some vicarious elimination through the skin. 



ACUTE NEPHRITIS 773 

Careful covering and rest in bed keep the skin relaxed and not only 
materially aid its functions but also relieve renal hyperemia, (g) 
Management of the bowels is as important as that of the skin. Saline 
catharsis lowers arterial tension and aids compensatory elimination. 
As salts often derange the stomach, an ounce should be given by 
rectum with two ounces of glycerine and one of water. One-half to 
one dram of compound jalap powder or T V grain of elaterin is indicated 
when uraemia is imminent, (h) Treatment of uramiia (see Treatment 
of Chronic Nephritis). For suppression of urine a full warm bath 
lasting fifteen to twenty minutes should be given; a hot pack should 
be applied followed by wrapping in blankets and covering heavily 
with a rubber sheet; or the alcohol sweat or hot-air sweat may be 
given as described under Treatment of Chronic Nephritis. Cups 
applied to the back may divert blood away from the kidneys, because 
the vessels of the loin anastomose with those of the kidney. Pilocarpin 
hydrochlorate, gr. ^ to J in adults, and one-half as much in children, 
causes profuse sweating and salivation but long ago the author aban- 
doned its use after witnessing two deaths from sudden pulmonary 
oedema in patients with apparently strong hearts; of course it should 
never be employed when the heart is weak. Active, rapid catharsis 
is effected by giving two drops of croton oil on the tongue; this may 
be repeated in two hours if necessary. If uraemic symptoms (in an 
cedematous patient) appear slowly, an incision two inches long should 
be made over the lower tibiae down to the bone, thereby directly drain- 
ing away the serum with its retained toxins; this is better than the 
use of small punctures, or Southey's capillary tubes, which are attended 
by all the dangers of puncture-wounds. If uraemia develops suddenly, 
the legs should be incised and a pint or more of blood should be 
withdrawn from the veins of the arm; whether venesection relieves 
the circulation mechanically or removes toxins is still a matter of theory, 
but practically, relief is often obtained. It should be followed by sub- 
cutaneous normal salt infusions — or plain water without the salt — 
which stimulate the heart and kidneys and lower the molecular con- 
centration of the blood. Pleural or ascitic hydrops should be aspirated. 
The heart must be stimulated by strychnine and digitalis as in cardiac 
insufficiency, though hypodermics are better than oral administration. 
A hypodermic of morphine is beneficial and harmless when there is 
much dyspnoea and restlessness. Chloral and bromides modify sudden 
convulsions (v. Chronic Nephritis). (Edema of the lungs (q.v.), 
vomiting, and diarrhoea, are caused by several factors, viz., cardiac 
stasis, uraemia, oedema of the alimentary mucosa, and the vicarious 
elimination of urea, which breaks up in the digestive tract into irritat- 
ing ammonium; vicarious vomiting and diarrhoea should not be 
checked at once; if persistent, the vomiting is treated as outlined 
in chronic gastritis (q.v.) or typhoid; gastric lavage is beneficial, and 
dilute hydrochloric acid, ttjjx to xv, neutralizes the ammonium. (/) 
In convalescence, iron and other mild tonics should be given, irritating 
foods and beverages interdicted, exercise carefully restricted, and cold 



774 DISEASES OF THE KIDNEY 

and exposure should be avoided by sending the patient, if possible, 
to a warm climate. 

(B). CHRONIC NEPHRITIS. 

Our knowledge of chronic Bright's disease dates from Richard 
Bright's communications in 1827. Aetius, Avicenna, Cotugno (1770), 
and other writers, mentioned the association of hydrops and albumin- 
uria, but to Bright is due the credit of correlating renal disease, albu- 
minuria, and dropsy ; he also noted the etiological importance of alcohol 
and cold, as well as the cardiac hypertrophy, uraemia, brain hemorrhage, 
coma, convulsions, blindness, and the tendency to serositis. 

The following classification of nephritis is given as covering typical 
cases, though it must be borne in mind that combined or mixed types 
are equally frequent. As a cause of death, chronic nephritis ranks 
sixth, after pneumonia, tuberculosis, heart disease, endocarditis, and 
unknown causes. 



I. Chronic Parenchymatous Nephritis. 

Definition. — Chronic Bright's disease, with special involvement of 
the parenchyma (though the interstitial tissue is always affected), with 
much albuminuria, and with abundant formed elements in the urinary 
sediment. The affection constitutes 3 per cent, of all cases of disease. 

Etiology. — It may result from (a) infections, as tuberculosis (which 
causes 25 per cent.), malaria, and syphilis; (b) from exposure to cold 
and dampness; (c) from toxic factors, as alcohol and lead, and less 
frequently others, as mercury or arsenic; (d) from cardiac disease; 
14 per cent, of these cases develop nephritis, (e) Exhausting dis- 
charges, suppuration, and ulceration may cause it. (/) Acute nephritis 
seldom becomes chronic, though it is a somewhat predisposing factor. 
(g) Age and sex are of etiological importance. Most cases occur 
between twenty and fifty years of age; it is rare in children. Males 
are affected more often than females. 

Pathology. — Three types of the disease exist, besides the mixed 
forms. 

1. The "Large White Kidney" or "Inflamed Fatty Kidney."— This is 
never decreased in size and may weigh 10 to 12 ounces (300 to 360 gm.) 
and measure two or three times the normal size. 

Gross Characters. — The capsule is loose and non-adherent; the 
surface is smooth, yellow-gray, with prominent stellate veins, and 
sometimes has dots of hemorrhage upon it. On section the cortex is 
broader than normal, the striations are poorly marked, and when cut, 
streaks of fat may show; the glomeruli and convoluted tubules are 
yellow, and contrast with the gray bands of newly formed connective 
tissue. The medulla shows fewer changes, and is red, in sharp contrast 
with the light cortex. 



CHRONIC PARENCHYMATOUS NEPHRITIS 775 

Microscopic Characters. — The most essential change is hyaline 
and fatty degeneration and atrophy, chiefly in the convoluted tubules, 
in which lie desquamated epithelia and coagulated albumin. The 
glomeruli are always diseased, but to a varying degree; they are 
enlarged, their vessels show hyaline and fatty degeneration and nuclear 
multiplication; albumin is found in their capsules, and the epithelium 
is swollen, fatty, or even necrotic. The connective tissue is always 
increased, which histologically separates chronic nephritis from acute 
nephritis and mere degeneration. These changes are never equally 
diffuse. 

2. The "Large Red" or "Variegated Kidney." — Gross Characters. — 
It is also large, but is firmer than the kidney just described 
or that of acute inflammation, for it has more connective tissue, 
which may cause some tearing and loss of the cortex when the capsule 
is stripped off. The surface may be perfectly smooth. The cortex 
is swollen, indistinctly striated, dotted yellow from fatty glomerular 
change, or red from minute ecchymoses, and sometimes streaked yellow 
and red from similar tubular changes. 

Minute Characters. — These are essentially those of the large 
white kidney, with the exception that fatty degeneration is less marked, 
and connective tissue alteration and hemorrhages are more conspicuous. 

3. The Secondary Contracted Kidney. — This form may develop 
after a year or two from the above forms. Some consider it a primary, 
independent form. 

Gross Characters. — It is seldom decreased in size and may be as 
large as the "large white" or " large red kidney"; the name refers 
rather to its connective tissue than to any visible renal shrinkage. 
The capsule is adherent in places, and, when stripped, tears off small 
areas of the renal substance. The surface is rough and shows in some 
places reddish depressed areas (fibrous contraction or granulations, 
and parenchymatous atrophy) and in others yellow areas (which are 
more normal, though fatty). Section shows decrease in the cortex, 
corresponding to the reddish foci. It differs from the genuine con- 
tracted kidney (primary interstitial nephritis) in the following respects: 
it is secondary, much more rapid in development, contains fewer 
cysts, is more yellow, and its red granulations and yellow prominences 
are larger. 

Minute Characters. — Epithelial changes resemble those of the 
two forms described. The membrana propria of the tubules thickens, 
adheres, and obliterates many tubules. The glomeruli collapse, thicken , 
and shrink to small dark-gray granular bodies, which sometimes 
calcify. The retracted areas, capsular adhesions, and cortex shrink- 
age, correspond to connective tissue contraction. 

Symptoms. — The onset is in most cases gradual and insidious, the 
earliest symptoms being loss of strength, pallor, emaciation, simple 
decline of health, indigestion, anorexia, headache, shortness of breath 
on exertion, or chronic bronchitis. Sometimes there is tenderness over 
the kidneys. 



776 DISEASES OF THE KIDNEY 

1. Urinary Findings. — Except in the secondary contracted kidney 

(a) the urine is decreased to seven ounces or a quart (200 to 1,000 c.c); 

(b) the color is dark yellow-red, opaque, or rarely smoky; the urates 
are held in suspension by the albumin; sometimes its surface is shim- 
mering from fatty cells and casts; (c) the specific gravity is 1,020 to 
1,040 and (d) the reaction is acid; (e) albumin is almost never absent, 
is more abundant in the day time than at night, and amounts to 1 to 3 
per cent, and one-half to one ounce (15 to 30 gm.) daily; it coats the 
bubbles formed by agitation of the specimen and preserves them for 
a long time. (/) The absolute amount of solids is generally decreased; 
for example, the urea (which normally constitutes 90 per cent, of the 
nitrogen output and amounts to about an ounce [35 gms.] daily), 
kreatin, and sodium chloride, are decreased, and the freezing point of 
the urine is lowered (v. i.). (g) The sediment is abundant, and hyaline, 
granular, fatty, and epithelial casts abound (first noted by Simon and 
Nasse); coarsely granular and waxy casts appear late in the disease; 
the granular type is due chiefly to fat particles, which may darken the 
casts. They have been long regarded as significant of nephritis. 
Key, Nothnagel, Rosenstein, and others afterward, observed their 
occurrence in the urine of otherwise normal individuals, and of late 
there has been a tendency to underestimate their importance. Accord- 
ing to Senator, casts originate in the kidney chiefly from epithelial 
cells, and always indicate some renal disease. They may be dissolved 
in the bladder by the pepsin contained in the urine (Sehrwald). Leuko- 
cytes and fatty epithelia, and, in some forms of nephritis, red cells, 
occur in considerable amounts. In Ackermann's case no casts were 
found in the urine, but were found in masses in the renal pelvis at 
necropsy. 

In the secondary contracted kidney the urinary findings are the 
same except that the urine amounts to three pints or two quarts (1,500 
to 2,000 c.c), is clearer, is somewhat lower in specific gravity, and 
contains somewhat less albumin and casts. 

2. (Edema. — (Edema is very frequent. Its absence argues for little 
glomerular involvement. It commences about the eyes, changes its 
location readily, and is at first evanescent, but soon becomes general, 
obstinate, and ominous. It is more pronounced in the "large white 
kidney" than in other types and increases as the urine decreases. The 
puffy eyes, pale swollen cheeks, dull expression, distended abdomen, 
and shapeless wrists and ankles, often tempt one to a snap diagnosis. 
The serous and mucous membranes are similarly involved, though to a 
lesser degree, and, also, as possible terminal events, pulmonary or cere- 
bral oedema may develop. (Edema is caused (a) by hypalbuminosis 
and hydremia of the blood (Bright's theory), or (6) by alterations in 
the vessel walls, i.e., abnormal permeability, a theory advanced by 
Cohnheim and Lichtheim. 

3. Anaemia. — Ansemia distinguishes chronic parenchymatous ne- 
phritis from the genuine interstitial type. There is usually retention 
of urea, uric acid, and chlorides; sometimes the blood is cloudy. 



CHRONIC INTERSTITIAL NEPHRITIS 777 

4. Cardiovascular Findings. — The pulse is more often small, soft, 
rapid, and associated with a weak apex, indicating dilatation, than 
tense and associated with a loud second aortic tone and strong apex, 
indicating hypertrophy. Secondary contraction and mixed nephritis 
are likely to develop findings similar to those of the genuine inter- 
stitial nephritis; Senator finds hypertrophy with dilatation (eccentric 
hypertrophy) in parenchymatous, and simple or concentric hypertrophy 
in interstitial nephritis. Myocardial degeneration is common. 

Complications, and Causes of Death. — (a) Marasmus results from 
the ansemia, indigestion, diarrhoea, oedema of the alimentary mucosa 
or its irritation by decomposed urea. (6) Intercurrent infections may 
result, as inflammation of the pleurae or pericardium, cellulitis, and 
especially pneumonia; in one instance the writer saw acute necrosis 
and sloughing of the scrotum, after which the patient improved re- 
markably; many pneumonia deaths really result from nephritis. 
Other complications are (c) adema of the lungs, larynx, serous sacs, 
and extremities, impeding respiration and obstructing the arterial flow 
in the peripheral vessels; (d) hemorrhages (in 8 per cent.) in the brain 
or other organs; (e) retinitis (in 18 per cent.); (/) urcemia, with its 
numerous nervous, circulatory, and digestive symptoms (v. Inter- 
stitial Nephritis) ; (g) acute exacerbations, particularly in the chronic 
hemorrhagic type; and (h) cardiac insufficiency. 

Diagnosis. — The diagnosis rests upon three cardinal symptoms: 
(a) the urinary, which are characteristic when twenty-four-hour speci- 
mens are carefully and repeatedly examined in every case coming 
under our care; (b) the anasarca, which is usually present, though 
sometimes absent in secondary contracted kidney and in Wagner's 
hemorrhagic type; and (c) the an&mia. (For differentiation, see 
Differential Table of Diffuse Renal Diseases, pages 796-797.) 

Prognosis. — Though some cases which suggest an arrest of the 
process are found at autopsy, and some cases may recover after a 
year or two, the clinical course is usually progressive and fatal. Dropsy 
usually causes death in a few months to a year, though the author has 
seen three typical cases apparently recover after two and a half years ; 
these cases did not result from acute infections like the cases of recovery 
after one to two years reported by Senator and Rosenstein. The 
outlook is slightly better in children than in adults. The " large, 
white kidney" causes death in one-half to one year, the "large, varie- 
gated kidney" in one and a half to three years, and the secondary 
contracted kidney in one and a half to three years. The treatment 
is considered under chronic interstitial nephritis (q.v.). 

II. Chronic Interstitial Nephritis. 

Definition. — A primary, interstitial, contracting sclerosis of the 
kidney, characterized clinically by abundant urine of low specific 
gravity, with small amounts of albumin and few cellular elements; and 
by marked cardiac hypertrophy, arteriosclerosis, retinitis, and uraemia. 



778 DISEASES OF THE KIDNEY 

This genuine contracted kidney (primary contraction) must not be 
confused with secondary contracted kidney, arteriosclerotic contrac- 
tion, embolic contracion or the contraction resulting from ascending 
infection — e. g., cystopyelonephritis. 

Frequency. — In ten years Eichhorst treated 31,562 cases, of which 
409 (1.4 per cent.) had contracted kidneys; he finds this form six and 
a half times as frequently as the parenchymatous form, though with 
us the latter is at least equally frequent. 

Etiology. — The etiology is essentially that of arteriosclerosis, with 
which contracted kidney has a three-fold relation : (a) arteriosclerosis 
may cause the arteriosclerotic kidney; (b) contracted kidney may 
cause arteriosclerosis; or (c) both may result from a common cause. 
The noxa or toxin reaches the kidney through the blood stream. 

The disease may result from (a) chronic alcoholism, especially when 
combined with exposure or over-eating; (b) chronic lead-poisoning, 
proven to be a cause by clinical and experimental evidence (Lancereaux 
and Ollivier); (c) gout (Todd), caused by uric or oxalic acid and 
the alloxur bodies; (d) syphilis; (e) diabetes (Senator), caused by 
sugar, acetone, oxybutyric acid, or kreatin; the diabetes lessens or 
ceases when induration develops; (/) age; it begins between the ages 
of thirty and fifty, and is clinically manifest after fifty years of age. 
Sawyer collected 24 cases in children, 13 of whom were under ten 
years, (g) Sex is an etiological factor. The disease is two to three 
times as frequent in men as in women. In the infantile form most 
cases occur in girls, (h) Other infrequent causes are acute nephritis, 
the kidney of pregnancy, hereditary tendency as in Dickinson's series 
through four generations, and endocarditis. 

Pathology. — It is undecided whether the process is inflammatory 
or atrophic; Weigert believes that cellular degeneration occurs first 
and induration follows. 

Gross Pathology. — (a) The kidneys are contracted even to one-third 
their original size and may weigh but 1.6 ounces (50 gm.), or 0.6 ounces 
(21 gm.); contraction is rarely symmetrical in both, (b) Their con- 
sistence is increased, (c) The capsule is thick, tendinous, wrinkled, 
vascular, and adherent, and strips off particles of cortex when removed. 
(d) The surface is uneven; there are small reddish or sometimes paler 
prominences, measuring 0.5 to 5 mm. and representing the* more 
normal tissue; the paler retracted areas are fibrous retraction, (e) 
Small cysts are frequently found, usually with clear contents; they 
vary in number and their size ranges from that of a pin-point to that 
of a cherry; they apparently result from glomerular and tubular 
constriction by connective tissue (retention cysts). (/) On section the 
cortex is shrunken, even to 1 mm., is irregular and gray from fibrillar 
connective tissue. The medulla is less changed, though also shrunken; 
pale fibrous lines alternate with red dilated vessels; uric acid or 
calcium salts are deposited, (g) The pelvis is large and much fat 
surrounds the kidney. 



CHRONIC INTERSTITIAL NEPHRITIS 779 

Minute Pathology. — The changes are largely cortical, focal, asym- 
metrical, and interstitial, (a) The glomeruli early contain round cells, 
nuclear increase, desquamated cells, and albumin; later they atrophy 
from degeneration of the afferent artery ; multiplication of cells is noted 
between the loops, and hyaline change occurs in the glomerular vessels; 
in the extreme stage the glomeruli become hyaline and fibrous; some 
tufts remain normal and others may visibly hypertrophy, Sabourin's 
compensatory adenomata, (b) The epithelium is always changed, 
though much less than in parenchymatous forms ; in the sunken areas 
many tubules disappear, and degenerated cells are seen in the promi- 
nent surface granulations; in the medulla the collecting tubules are 
larger, even cystic, and are filled with colloid material, (c) The con- 
nective tissue is increased everywhere, but more in the cortex than in 
the medulla; round cell infiltration occurs early and induration late; 
the vessels are sclerotic in all their coats, but especially in the intima, 
and many writers consider that the vascular changes are the earliest 
and causative alteration. 

Symptoms. — Long latency for years, insidious onset, and protracted 
compensation by heart hypertrophy, are characteristic of this type. 
Many cases are first discovered during an acute infection, as pneu- 
monia; they may be found on examination for life insurance, or at 
the coroner's autopsy after accidents. It may appear to be a phys- 
iological, intermittent, or cyclic albuminuria. Polyuria, cardiac symp- 
toms, retinitis, indigestion, or depreciation of health, may be the first 
symptoms. The oedema, pronounced urinary findings (in a single 
specimen) and ansemia of chronic parenchymatous nephritis, are 
seldom conspicuous and almost never early symptoms in this type. 
The condition may be first declared by heart incompetence, ursemic 
coma, or convulsions. 

1. Urinary findings are generally the earliest signs. Twenty-four- 
hour specimens should be examined (with a fresh specimen for micro- 
scopic examination) repeatedly in doubtful cases, (a) The amount, 
which is at first normal, is gradually increased (polyuria); this is a 
frequent cause for consulting the physician. The urine is also passed 
too frequently (pollakiuria) , especially at night; this is always sus- 
picious when the prostate is normal. In well-developed cases it totals 
two to three quarts (2 to 3,000 c.c), rarely more, though 8 to 10 quarts 
(8 to 10,000 c.c.) were passed in a case of Lecorche* and Talamon and 
12 quarts in BarteFs case, (b) It is pale and (c) weakly acid, (d) 
The specific gravity averages 1,010 (1,005 to 1,012). (e) A permanent 
foam due to the albumin is frequent. (/) Albumin is present in 
most cases, but is not abundant; the merest traces are found up to 
8 grains (0.5 gm.) pro mille, and a daily total of one-half to one dram 
(2 to 5, rarely 10 gm.). It is often absent in single specimens, espe- 
cially in the morning, whence a twenty-four-hour specimen should 
always be examined. Delicate tests (v. Albuminuria) are often neces- 
sary. It may appear only after eating, exercise, excitement, or fatigue, 
whence its greater frequency toward night; it may increase after 



780 DISEASES OF THE KIDXEY 

dyspepsia or bronchitis. Senator's statement that its alleged absence 
is due to an arteriosclerotic kidney and not to interstitial nephritis 
is not invariably correct, according to personal experience. Albumin- 
uria may be absent for weeks or months, (g) Solids are decreased, 
i. e., the urea, uric acid, ammonium, chlorides, and phosphates. The 
determination of the freezing point, cryoscopy, was first employed by 
Koranyi to estimate the amount of soluble molecules in the blood 
and urine. The blood, when there is deficient renal excretion, freezes 
at a lower point, because its molecular concentration is greater; this 
point is 0.56° C. (with 0.02° physiological variation in either direction), 
lower than that of distilled water. The urine freezes at a higher point 
than normal, as its molecular concentration is less. Normal urine 
freezes at 0.9° C, lower than distilled water; in chronic nephritis the 
urine freezes at 0.5 or even 0.2° below that of water. The smaller 
the molecules, the greater their influence in lowering the freezing 
point; the chloride molecules are more potent, therefore, than those 
of the urea group. Increased molecular concentration of the blood 
usually (not always) indicates disease of both kidneys. Cabot recently 
concluded that cryoscopy is of no great value in medical cases, (h) 
The rapidity of elimination is decreased. Methylene blue was em- 
ployed by Achard and Castaigne (1897) to test this point. One cubic 
centimeter of a 5 per cent, aqueous solution is injected subcutaneously; 
normally it should stain the urine in one-half to one hour, reach a 
maximum in three to four hours, and cease in thirty-six to seventy- 
two hours; elimination may be nearly or even more rapid, in chronic 
parenchymatous, but it is much slower than normal in interstitial 
nephritis (Bard). The permeability of the kidneys may also be tested 
by a hypodermic injection of one cubic centimeter of a one-half 
per cent, solution of phloridzin (Achard), which produces glycosuria 
in normal kidneys; phloridzin glycosuria is reduced or absent in 
interstitial nephritis. A dilution test may be made. Drinking of large 
amounts of water raises the freezing point of the urine to 0.3, 0.2, or 
0.1°, in interstitial nephritis and in health, but does not raise it in par- 
enchymatous nephritis, (i) The sediment is scant, absent, or can be 
obtained only by the centrifuge. Hyaline, granular, and epithelial 
casts, are found in small numbers when the light is moderated by the 
diaphragm; the granular form is found in some cases only after 
repeated search; the granular casts are often wide, originating in the 
dilated tubules of the medulla. A few epithelia, leukocytes, and crystals 
of uric acid and oxalate of lime, are found. Red cells are infrequent. 

The urinary findings are somewhat modified by intercurrent uraemia, 
fever, and heart failure, all of which concentrate the urine, raise its 
specific gravity, and deepen its color. 

2. Cardiovascular symptoms were noted by Bright, but their signi- 
ficance was first established by Traube. They appear in 50 to 90 
per cent, of cases, and later than the urinary findings. Cardiac hyper- 
trophy is more quickly detected clinically than pathologically, especially 
in the young, because the urine is increased early before the physical 



CHRONIC INTERSTITIAL NEPHRITIS 781 

signs of hypertrophy prevail, and again because concentric hyper- 
trophy is present long before dilatation appears. Emphysema may 
obscure the precordial evidences of hypertrophy, such as the heaving 
apex beat, and one must therefore depend on the evidences presented 
by the tense pulse, the hardness of the arteries, the sphygmographic 
tracings with a square apex, the loud ringing second aortic tone, or 
other manifestations of increased arterial tension, as epistaxis, vertigo, 
headache, tinnitus, palpitation, or cardiac asthma. Strassburger, Sahli, 
and Fellner, estimate the normal systolic blood pressure at 125 mm. 
and the diastolic at 29 mm.; in interstitial nephritis the systolic pres- 
sure may mount to 200 mm. or more. High tension is one of the most 
constant and early symptoms; its early occurrence leads some writers 
to incorrectly regard contracted kidney rather as a disease of the 
arteries than of the kidneys. The cause of the hypertrophy is not 
definitely known; theories of mechanical obstruction to the blood-flow 
by the renal contraction, and of vasomotor constriction excited by 
retained waste substances, have been advanced. Though hypertrophy 
should be looked for in interstitial rather than in parenchymatous 
nephritis, it must never be forgotten that the two types often mingle 
with the urinary findings of the "large white kidney" and the cardio- 
vascular findings of a renal contraction. In the last stage of contracted 
kidney the hypertrophied heart weakens, the pulse tension falls, the 
apex becomes weaker, a systolic murmur appears from myocardial 
insufficiency, and Potain's gallop-rhythm, a sign of heart fatigue, is 
heard. 

3. Retinitis may be the first declaration of the disease, and may 
come under the observation of the ophthalmologist. It occurs more 
frequently than in any other renal lesion, 22.4 per cent. (Groenauw) 
to 28 per cent. (Eates). Its various forms are stellate white areas of 
fatty and fibrous tissue, a white zone surrounding the disk, degenera- 
tion of the disk, retina, or of both together, "flame-like" hemorrhages, 
and the choked disk whose large veins are compressed where the 
arteries cross them. (See Plate VI, Fig. 8.) The retinitis albuminurica 
is not specific, identical findings occurring in other conditions. 

4. Uraemia is the most dreaded and frequent complication; its 
nature and immediate cause are unknown; it can only be stated 
that it is an auto-intoxication, due to disturbance of renal function, 
probably with retention within the blood of nitrogenous substances. 
Further explanations are wholly theoretical, such as decreased alkalin- 
ity of the blood (acidosis); failure of the normal "internal secretion" 
of the kidney; the toxic action of abnormal products of metabolism 
or breaking up of the proteids, resulting from destruction of the renal 
tissue (nephrolysins, Ascoli); it is not due to retention of urea alone, 
nor to mechanical conditions alone, as oedema or anaemia of the brain. 
It occurs most often in chronic interstitial, next in acute, then in chronic 
parenchymatous nephritis, and is much less common in other diseases 
of the urinary tract, as pyelonephritis, etc. 



782 DISEASES OF THE KIDNEY 

Ursemic symptoms may be acute or chronic, but will be considered 
as nervous, respiratory, cardiac, and digestive. 

Nervous Symptoms. — (i) Acute convulsions (eclampsia) are due 
to irritation of the cortex by toxins; they closely resemble the epi- 
leptic attack. There are usually prodromes, as pain or pressure in 
the head, migraine, neuralgia, insomnia, vertigo, visual disturbance, 
tinnitus, nausea, vomiting, or dyspnoea; there is usually no " epileptic 
cry." In less than a day clonic or tonic convulsions appear, usually 
generalized (sometimes Jacksonian) and involving especially the flexor 
or extensor muscles of the arms and legs; the abdomen is retracted; 
there are dyspnoea, cyanosis, and involuntary evacuations; the reflexes, 
especially the patellars, are increased ; the pupils are wide and without 
reaction; the pulse is full and slow before the attack but becomes 
rapid during the convulsions. The skin becomes covered with sweat 
and the temperature is usually elevated. The convulsions cease after 
fifteen to thirty minutes and coma intervenes, during which the con- 
vulsions may recur. Death is the usual outcome, but recovery is 
possible, as in one of the author's cases in which the anterior third 
of the tongue was bitten off. (ii) Other motor manifestations. The 
most concise general statement regarding ursemic nervous phenomena 
is as follows: paralysis affects especially the sensorium, to a lesser 
degree the special senses, and rarely motility; irritation seldom affects 
the sensorium (e.g., produces delirium), it principally acts upon the 
motor paths (convulsions) and very seldom upon the special senses. 
Ursemic convulsions are usually general but may resemble focal 
symptoms, such as convulsions of only half the body, for instance, of 
one-half the tongue, of the left arm and leg, or deviation of the head 
to the left. They may rarely occur with convergent strabismus, facial 
spasm, Jacksonian epilepsy, nystagmus, tremor, localized trembling 
and twitchings, muscular cramps, grinding of the teeth, tetanic con- 
vulsions, trismus, convulsions on one side and contractions on the 
other, rigidity of the neck or opisthotonos. In seven cases, seen by the 
author, the symptoms were those of an acute focal brain lesion; in 
two, which were treated by lumbar puncture, relief was immediate. 

Paralyses in uraemia are infrequent, are chiefly transitory hemi- 
plegias and are due to cerebral adema, capillary hemorrhage, softening, 
apoplexy, inflammatory foci or cortical overstimulation by toxins. 
Hemiplegia may occur with aphasia, amnesia, deafness, crossed oculo- 
motor paralysis, glossoplegia, or conjugate deviation of the eyes. The 
author has reported five cases in which ursemia resembled meningitis 
very closely. Other cases have been suggestive of brain tumor, (iii) 
Acute coma often occurs without antecedent eclampsia, being preceded 
by headache, stupor or apathy; coma may last for days or even months. 
(iv) Psychical symptoms. One of the most common chronic symptoms 
is a characteristic restlessness and anxiety. Obstinate headache of a 
dull, throbbing nature is common; it often begins in the early morn- 
ing; it may be occipitial, or hemicranic. Insomnia is common, though 
during the day the patient is often sleepy. Delirium and mania are 



CHRONIC INTERSTITIAL NEPHRITIS 783 

more frequent in chronic nephritis in adults than in juvenile cases; 
melancholia and delusional insanity occur; these mental states may 
assume medico-legal importance as to the testamentary capacity of the 
patient, (v) Special senses. Sudden, complete and bilateral blindness 
is cortical in origin; this amaurosis may be an initial symptom; there 
are usually no retinal findings and the condition lasts but a few hours, 
though in exceptional cases oedema of the disk (Schmidt), or even 
choked disk is found. The pupils are wide and without reaction in 
acute eclampsia, but are small and mobile in chronic uraemia. There 
may be sudden or gradual uraemic deafness and tinnitus aurium. 

Respiratory or Cardiac Symptoms. — Dyspnoea is very com- 
mon. It is sometimes toxic and central, occurring in close parallelism 
with cerebral manifestations. In other cases asthma uraemicum 
develops when the mind is absolutely clear, and it is then correctly 
referred to the heart. Prodromal slowing of the heart to 40 to 60 
beats is frequent in incipient uraemia. The dyspnoea may be continu- 
ous or paroxysmal and is often nocturnal. Cheyne-Stokes breathing 
may develop in the day time or during sleep and is always an un- 
favorable sign, though recovery is possible. Obstinate hoarseness and 
a rare form of laryngeal spasm are recorded. 

Digestive Symptoms. — These rank second to the nervous symptoms 
in frequency. The breath is often offensive and sometimes has an 
odor of urine, which condition Senator refers to trimethylamine; he 
considers it of poor prognostic value, for it often precedes eclampsia. 
The tongue is foul, the mouth is inflamed and the saliva is frequently 
increased. Nausea and vomiting are partly central and partly local 
from decomposed urea, eliminated vicariously into the stomach; the 
same may be said of hiccough and diarrhoea. All these symptoms may 
be very acute. Diarrhoea may be serous or dysenteric from the Bac. 
dysenteriae (Flexner). Mathieu and Roux in a recent study of 23 
cases of "uraemic ulcers" found them chiefly in cases of advanced 
nephritis in subjects under twenty years old; they rarely occur in the 
stomach; diarrhoea is common, but bowel hemorrhage and constipa- 
tion are rare. They are seemingly produced by necrosis due to tox- 
aemia, though sometimes secondary to submucous haematomata. Heal- 
ing is very rare and the prognosis is almost always unfavorable. 

5. Other Complications and Symptoms. — (a) Various hemorrhages 
occur; of the brain in 7 to 17 per cent, of cases; also in the dura, 
skin, nose, bronchi, stomach, bowels, uterus, conjunctiva or retina. 
The author has observed 9 cases of profuse gastro-intestinal hemor- 
rhages in uraemic subjects, (b) Inflammations may develop. Chronic 
bronchitis always suggests kidney disease. Pericarditis, pleuritis, and 
pneumonia especially, may develop as terminal infections. A large 
number of deaths from pneumonia is due to nephritis which was 
previously unnoticed. Laryngitis and acute (inflammatory) oedema 
glottidis may occur, (c) (Edema is a late symptom and results not 
from the nephritis unless it is of the mixed type, but from failing of 
the heart. Ascites also is nearly always cirrhotic or cardiac, (d) The 



784 DISEASES OF THE KIDNEY 

skin is usually dry and harsh and is sometimes covered with urea 
crystals — the "urea frost" or uridrosis. Itching, erythema, urticaria, 
eczema and numbness or "dead fingers," unusual susceptibility to cold 
(crysesthesia), neuritis, rheumatoid pains or clubbing of the fingers 
are probably toxemic. 

Diagnosis of Chronic Interstitial Nephritis. — There are three car- 
dinal findings, cardiovascular, urinary and retinal; and as Senator 
says, he who invariably examines the urine and heart in every instance 
rarely fails to diagnosticate nephritis correctly. 

Cardiac Symptoms. — The very interdependence of cardiac and renal 
changes may prove to be a source of clinical confusion; thus primary 
cardiac disease may cause renal congestion, embolism or even acute 
or chronic nephritis; again alcohol or syphilis may be a common 
cause of arteriosclerosis, myocarditis and nephritis; and finally, the 
heart lesion may be wholly secondary to renal disease. Simple renal 
stasis is considered in the differential table given below. In terminal 
cardiac weakness caused by contracted kidney, the hydrops, dyspnoea, 
rales or systolic murmur may suggest myocarditis with renal stasis; 
gallop-rhythm is more common in the heart of renal disease than in 
primary cardiac affections. 

The Urinary Findings. — In diabetes mellitus there is an increased 
flow of urine, in which the high specific gravity, glycosuria and less 
prominent heart findings are distinctive; in diabetes insipidus, the 
absence of albumin, casts and cardiac changes are characteristic; 
and pyelitis is characterized by albumin and pyuria but not by casts 
or cardiac changes. In the arteriosclerotic kidney, arterial and cardiac 
antedate the urinary changes (the converse is true in interstitial neph- 
ritis), the specific gravity is higher, albumin less in amount and in 
frequency of occurrence, and the course is much more rapid. For 
differentiation from other Diffuse Renal Diseases See Table, 
pages 796-797. 

Diagnosis of Ursemia. — Skull-fracture, miliary tuberculosis, lepto- 
meningitis, cerebral abscess, sepsis and other diseases may be falsely 
diagnosticated ursemia, simply because nephritis is also present. 
Senator has said that without a previous history we can often only 
diagnosticate a renal disease and suspect the presence of other (latent) 
affections. The danger of mistaking ursemic symptoms, as hemicrania, 
nervous symptoms, dysentery etc., for independent disease is greater 
in direct ratio to the difficulty of diagnosis of the nephritis itself and 
many authors have remarked on the lack of correspondence between 
the clinical and pathological findings in nephritis. According to 
Leube, ursemic intoxication is assumed to be the cause of nervous 
symptoms only when other causes may be excluded, because in the 
course of renal disease, organic nervous lesions, as hemorrhage and 
meningitis, may simulate ursemia. Though the urine is usually de- 
creased before an attack of uraemia, Liebermeister instances a case 
in which, immediately before a ursemic seizure, both urine and urea 
were increased two-fold, hours before ursemia developed. Biermer 



TREATMENT OF CHRONIC NEPHRITIS 785 

reports an anuria which lasted two hundred and twenty-two hours 
before uraemia developed. 

Apoplexy is probably present when pressure symptoms, as vomiting, 
or slow, tense pulse, complete hemiplegia, or conjugate deviation, exist; 
it is rarely completely simulated by uraemia. Meningitis, insolation, 
or the coma resulting from alcohol or opium are rarely simulated; 
in very exceptional instances focal symptoms and fever may cause 
diagnostic error. The author has seen a few cases in which uraemia 
simulated typhoid or sepsis by the constant high temperature, though 
the autopsy disclosed nephritis, and two cases in which there was 
no bacteriological evidence of secondary or terminal infection. 

Prognosis of Interstitial Nephritis. — Because the disease is insid- 
ious in onset, it is too often detected only when the patient suffers 
from cardiac insufficiency, beginning uraemia, apoplexy or intercurrent 
inflammations; for this reason this incurable malady is rather seldom 
treated in its early stages. The clinical course usually runs five to 
ten years after albuminuria is found; a longer duration is not uncom- 
mon; a course of twenty years is reported by Senator and Aufrecht, 
of twenty-three years by Oppolzer and of thirty by Rosenstein. Much 
depends on the docility and financial ability of the patient. Marked 
arteriosclerosis naturally hastens the fatal issue. Retinitis is usually 
an ominous symptom; in Belt's 419 cases, 72 per cent, died in one, 
and 90 per cent, in two years. Retinitis increases the gravity of the 
outlook four-fold. Staub's and Gruening's figures are almost iden- 
tical. Webster, Wert, Hare, Mix, and the author have seen cases 
which lived from four to ten years after retinitis was found. Uraemia, 
pneumonia, apoplexy, and other complications are decidedly unfavor- 
able. 

Treatment of Chronic Nephritis, Parenchymatous and Interstitial. 

— Both forms are considered together, because they often blend (mixed 
nephritis). 

1. Prophylaxis. — Prevention and treatment of the cause have a very 
limited practical application. Irritating foods, excessive eating, all 
forms of intemperance, over-work, neglect of infections, and dyspepsia 
come under this head, but are usually treated too late. 

2. Rest, Exercise. — The kidneys should be relieved by rest in the 
horizontal posture, because exertion and even the erect position, which 
per se may cause albuminuria, only increase preexisting albuminuria. 
If in severe cases exercise seems advisable, it should be given passively 
with the patient in the recumbent posture. The rest should be abso- 
lute as long as the heart is weak, the urine scanty, or hydrops con- 
spicuous. The importance of rest in bed was recognized by Bright 
and Bartels. When there is moderate renal involvement, or in the inter- 
vals of improvement, relative restriction of exercise should be enforced. 
Rest in bed lessens the amount of waste products to be eliminated by 
the kidneys and so protects the skin and dilates its vessels that the 
cutaneous functions become more active and relieve the vascular 

50 



786 DISEASES OF THE KIDNEY 

hypertension, just as a patient with a cold should remain in bed, in 
order to increase the activity of the skin and promote that of the 
kidneys. The author has treated two severe cases of parenchymatous 
nephritis by rest in bed for a year, and absolute recovery resulted. 
It is a question if lying covered in bed is not one of the reasons why 
nephritics pass more urine at night than in the day time. Fatigue, 
dampness, and cold must be avoided; these indications are best 
carried out by rest in bed during the time of severe symptoms or of 
acute exacerbations, and by relative rest and warm clothing in cases 
of moderate severity. Practitioners do not sufficiently insist on psy- 
chical rest; in men leading a strenuous life, moderate nephritis has 
often decreased and sometimes disappeared when nervous tension 
was relieved; too often these subjects take physical exercise or courses 
of training after they are already exhausted by head-work; in any 
event exercise should supplant work and not be taken after hard 
nervous strain. 

3. Springs, Climate. — "Cures" at water resorts have the general 
advantage that the importance of diet and hygiene is often much im- 
pressed on the patient; the psychical or suggestive element is also 
an important therapeutic agent. Diffuse nephritis (with considerable 
parenchymatous and interstitial change) is most benefited. Only 
patients without oedema or serious heart involvement should be sent 
to such places as Poland Springs, Bedford Springs, Saratoga, Vichy, 
or Neuheim. A stay in the California, Mississippi, or North Carolina 
climate during the winter at least will materially benefit. 

4. Diet. — The diet must be non-irritative, must not especially tax 
the kidneys in its elimination, must not burden the circulation, and 
must maintain nutrition. Disease of the glomeruli alone may be com- 
pensated by vicarious excretion of water through the lungs, skin, and 
intestines, but disease of the tubules whose function is elimination of 
the end-products of albuminoid metabolism, cannot well be compen- 
sated by other structures, whence the indication is for limitation of 
albuminous foods and their replacement by fats and carbohydrates. 
The amount of albumin lost through the kidneys is small and can 
easily be offset by a glass or two of milk daily; in this respect 
nephritis differs from diabetes in which the system is irritated by 
unappropriated sugar and loses a vast number of units of heat and 
energy each day. Albuminous food is restricted only to spare irrita- 
tion of the excreting renal cells, and no absolute rule can be laid down 
for all cases. Chittenden has recently shown that we eat twice as 
much meat as we need. It is an obvious mistake to guage the severity 
of a nephritis by the degree of albuminuria, or to estimate improvement 
by the influence of diet upon the albuminuria alone. Fats as butter, 
olive and cod-liver oils, and cream, are very important, because they 
supply energy and heat units in place of the restricted albumin. As 
in diabetes, the restriction of diet must not merely concern renal 
irritation, but also, and most of all, the maintenance of nutrition, 
especially when the patient suffers from parenchymatous nephritis, 



TREATMENT OF CHRONIC NEPHRITIS 787 

the very form in which restriction of diet is theoretically most needed; 
anaemia and malnutrition are the most distinguishing features of the 
parenchymatous as contrasted with the interstitial type of nephritis. 
The individual patient must be considered more than the disease per se 
or the type of the disease. 

The milk diet is free of extractives, is easy of digestion, and is a diu- 
retic. It has its restrictions; it is bulky, over four quarts being neces- 
sary to maintain nutrition, and it therefore may cause dyspepsia; 
it lacks iron, but this can be easily compensated^, four quarts contain 
an excess of about 60 per cent, of proteid; it contains too much water, 
thereby possibly overloading the blood and straining the heart; and 
its phosphates and chlorides tax the kidneys. One to one and a half 
quarts of milk with a pint of cream, fats and carbohydrates (baby foods, 
sago, rice, or potatoes), will meet the needs of metabolism; and, some- 
times over half of the phosphates of the milk can be precipitated and 
kept in the intestine (and away from the blood and kidneys) by giving 
calcium carbonate gr. v to x with the milk (von Noorden). It should 
be taken slowly, in sips, and it should be remembered that it is a food 
and not a beverage. Milk was one of the chief articles of diet of the 
older masters in medicine; a very short time ago we heard that it 
contained an excess of water; now we are told it is excellent because 
it contains so little salt. Part-truths are misleading. 

In regard to a meat diet, there is much liberality at present, though 
probably the reaction in favor of the meat diet is extreme, as Strubell's 
recent experiments demonstrate that a meat diet promotes uraemia. 
The average daily amount allowed by von Noorden is three ounces 
(100 gm.). There is absolutely no difference between red and white 
meats, as to extractives, or purin bodies (Walker Hall, Kaufmann, 
Mohr and others). The eating of some meat is preferable to over- 
loading the stomach and bowels with a bulky vegetable diet, save 
when toxaemia (uraemia) is imminent. 

Raw eggs increase (perhaps induce) albuminuria; not more than 
two daily should be given. Substances excreted with difficulty include 
the following, according to von Noorden; urea (in meat), creatinin 
(in meat broths, extractives and to a less extent in eggs), urinary 
pigments (in haemoglobin), hippuric acid (in cranberries, fruits with 
pits, prunes, plums and gages), phosphates (in milk) and inorganic 
sulphates (in meat) ; uric acid and alloxur bodies, contrary to general 
opinion, are, according to von Noorden, eliminated readily; (they are 
found in glandular organs, — such as the thymus, sweetbreads, liver 
and kidney, — in broths, and according to Taylor, in coffee). The 
chlorides are especially to be avoided in parenchymatous nephritis 
with oedema. As pointed out by Widal, Lemerre, Javal, Mercklen 
and Courmont in 1903, administration of salt (which is retained in 
the blood) increases the body-weight, induces oedema and aggravates 
albuminuria, while "dechlorination" of the food reduces weight, oedema, 
and albuminuria. Probably the entire truth is not yet known; Rumpf 
(1905) found cases with oedema, uraemia and retinitis in which the 



788 DISEASES OF THE KIDNEY 

chlorides of the blood were decreased. Irritants, as cheese, relishes, 
horseradish, onions, rhubarb, asparagus, spices, sauces, broths, beef- 
tea and alcoholics should be absolutely avoided; tea and coffee must 
be taken with great moderation because they may aggravate or pro- 
duce nephritis (Penzoldt, Hubach). 

5. Water. — In regard to giving water, the same extremes of opinion 
are noted; fluids were once excessively restricted, but more lately 
undue quantities were recommended ; von Noorden states that flooding 
the vascular system with water overtaxes and damages the heart; 
"water can only be excreted by the kidney if the blood pressure is 
increased; it is difficult to demonstrate that the heart is damaged 
by excessive water drinking, but indirectly this can be shown, for 
many patients having weak hearts give a history of excessive water 
drinking for long periods of time; in such cases improvement is 
frequent if the ingestion of water is limited; about three pints (1,500 
c.c.) should be the average amount." Nevertheless relief of high 
arterial pressure and minor ursemic symptoms may follow copious 
drinking of water. 

The following therapeutic measures are but symptomatic. 

6. Diuretics. — These are generally useless and should be, for the 
most part, avoided. Diuretin is said to produce no renal hypersemia 
but to act directly on the epithelium and, according to Gruenwald, to 
sometimes reduce the albuminuria; it may be employed and some- 
times with success (v. Treatment of Valvular Disease). The use of 
diuretics is indicated by increase of hydrops, scanty urine, and immi- 
nent uraemia. The refrigerants (cream of tartar, 5 j) or potassium citrate 
(gr. xx to xxx) are the only safe diuretics ; they are thought to abstract 
water from the tissues and to convert urea, uric acid, and similar 
products into more readily excreted substances; they are apparently 
most active in the effervescent form. Basham's mixture (liq. ferri 
et ammonii acetatis) as a tonic and diuretic should be given in doses 
of but 1 or 2 drams. Diuretics which act through the circulation will 
be considered below. 

7. Hydrops. — Hydrops necessitates treatment because it prevents 
movement, threatens suffocation by pulmonary or laryngeal oedema, 
increases the danger of secondary infections, as erysipelas or cellulitis, 
embarrasses the circulation by pressure on the afferent capillaries and 
efferent lymphatics and venules, interferes with digestion, and in- 
creases the danger of ursemia. (a) Though cathartics may eliminate 
fluids as well as solids, drastics must be given with due care for the 
digestion and nutrition, pulv. jalapse co. 5 SS to 5j at night, or Epsom 
salts gss to j in the morning. (b) Sweats are generally given, possibly 
less so of late. Though the functional relation between the skin and 
kidneys cannot be overestimated, profuse sweating eliminates fluid 
rather than solids. Leube holds that sweats concentrate the blood 
and predispose to ursemia; he states that when a patient sweats one 
quart (1,000 c.c.) only 7 to 15 grains (0.5 to 1 gm.) of urea are evacuated. 
The author has more often seen aggravation of symptoms, or a fatal 



TREATMENT OF CHRONIC NEPHRITIS 



789 



issue result from sweating, than relief and hence prefers the old-fash- 
ioned full warm bath, recommended by Osborne and Liebermeister, 
to the more active methods. In this form of treatment an ice-bag is 
placed on the head to prevent brain congestion. Commencing with 
water at body temperature, this is raised five or six degrees. After 
twenty or thirty minutes the patient is removed and wrapped — with- 
out drying — in blankets. A hot-air bath may be given by placing a 
lamp under one end of a stove-pipe which runs by an elbow into a 
tent built over the patient, as illustrated in the following cut. Another 



Fig. 47. 




Sweat bath employed in nephritis. 

method is the alcohol sweat, in which hot bricks protected by flannel 
are placed around the heavily covered patient; equal parts of alcohol 
and water are poured on the bricks and the patient is covered again; 
the heat produces a steam vapor which is tolerated fairly well unless 
the heart is weak, when fatal collapse may ensue. It is often unsafe 
to give pilocarpine (v. Acute Nephritis) because it produces profuse 
salivation, vomiting, diarrhoea, syncope, and pulmonary oedema, (c) 
Mechanical relief by means of incision is superior to all other measures 
which must first bring the fluid with all its urea and extractives into 
the circulation, with the ever present danger of inducing uraemia; 
i.e., the already impure blood is again contaminated by the toxic 
deposits in the cedematous tissues. If the kidneys and other emunc- 
tories cannot relieve the blood, how can they remove the additional 
refuse in the anasarcous fluid, which maybe amounts to quarts, and 
comes to the blood from the tissues ? The author has experimented 
with mild cases, making deep incisions, three inches long, over the 
lower leg (not over the malleoli where infection from the feet is likely) 
whenever the hydrops is at all extensive. In testing the fluid evacuated, 



790 DISEASES OF THE KIDNEY 

there has frequently been 0.1 to 0.2 per cent, urea which may serve 
as a measure for other retained products of kindred nature; when 
quarts seep out during the first twenty-four hours, one is well justified 
in incising the legs, despite the slight danger of occasional infection. 
Sweats and drugs never achieve equal results. Free incision is ob- 
viously less dangerous than punctures or Southey's capillary tubes. 

8. The Circulation. — Treatment often resolves itself into the care 
and stimulation of the heart. Mental excitement, nervous strain, 
physical exertion, constipation, and tobacco, coffee, alcohol, and ex- 
posure to heat must be avoided. The more the heart hypertrophies 
the better is the outlook, although ultimate cardiac dilatation is the 
inevitable result of every hypertrophy. In the uraemic seizures, with 
precisely the same symptoms in other respects, the heart may vary; 
it may beat as strongly as in an apoplexy, or very weakly, (a) With 
cardiac over-action observed early in uraemia, the angiospasm or the 
high tension must be corrected by vasodilators. Iodides are beneficial 
when there is no urgency; they should be given in doses of grs. v to x 
t. i. d. ; iodism, and especially salivation, may result from renal 
retention. When extreme tension and imminent uraemia exist, tr. 
veratri viridi v$y to x every half hour for three or four doses may be 
given (though the author considers that the drug is injurious) or large 
doses of nitroglycerine, gr. ^o, until results are produced. The author 
believes that the vasodilators are often given to excess, as hyper- 
trophy and increased arterial tension are less pathological than com- 
pensatory conditions. Bleeding may so relieve the intracranial blood 
pressure as to remove for a while the uraemia, but too often it does not; 
salines may be given afterward, either subcutaneously or by rectum; 
they serve as a "lavage of the blood" and stimulate the kidneys if 
enough sound tissue be left to act upon. Increased intracranial tension 
may be relieved by lumbar puncture; the normal pressure of 120 
mm. (as indicated by the sphygmanometer) is often increased, some- 
times to five or six hundred mm. ; during the last year the author has 
seen marked and sometimes protracted relief in medical and eclamptic 
cases; the headache, vomiting, convulsions, and coma are often de- 
creased or entirely relieved. (6) When the heart is weak, rapid, 
irregular, or galloping, cardiac stimulation by digitalis and strychnine 
is indicated. Infusion of digitalis by mouth may cause vomiting and 
TTj^ij to v of the fluid extract may then be given hypodermatically or 
by rectum. Its combination with squills or calomel is inadvisable; 
the latter may cause the most intense salivation; in one case necrosis 
of the entire tongue occurred. Cardiac unrest, palpitation or dyspnoea 
should be relieved by a hypodermic of morphine, by application of 
ice to the heart, or by champagne, nitroglycerine, bromides, and valer- 
ian. Venesection lessens the molecular concentration of the blood 
(i.e., its toxicity) and relieves the laboring heart; infusions act in the 
same way; an excess of salt may be given (v.s. "dechlorination") in 
the infusions; when they are repeated, the salt should be left out, 
for it may produce oedema of the lungs. Pilocarpin and sweats are 



PASSIVE CONGESTION OF THE KIDNEY 791 

distinctly contra-indicated, because they over-tax or fatally depress the 
heart. Von Ziemssen gave champagne and digitalis by mouth as 
long as the patient could swallow, and then digitalis by rectum or 
hypodermatically and camphor subcutaneously. 

9. Vomiting. — Vomiting and diarrhoea are as often vicarious as 
toxsemic and should not be checked at once. Gastric lavage and 
colonic flushings are beneficial. 

10. Convulsions. — For convulsions, hypodermics of morphine should 
be given, as advised by Loomis and Mackenzie; the author never saw 
harm result from its use, though medical opinion is generally against 
it. Chloral (gr. xv every hour for not more than four doses), aids the 
morphine, while bromides generally act too slowly. 

11. Operation. — Surgical treatment is still sub judice. It is certain 
that many cases of " decapsulated " kidney were not genuine nephritis, 
but rather albuminuria from floating kidney, or ascending infection. 
Again, it is still a question whether chronic nephritis is merely a renal 
disease or perhaps a result of a general condition of the blood; this 
idea was advanced by Semmola, and is not yet disproven. 



(C). PASSIVE CONGESTION— INFARCTION. 
1. Passive Congestion. 

Venous hyperemia is an important renal lesion, contrasting with 
arterial hypersemia, of which latter little is definitely known, though 
it occurs in renal inflammation, left ventricle hypertrophy, diabetes, 
perhaps also in nervous lesions and after the administration of diuretics. 

Etiology. — (a) Among the chief causes of general stasis are cardiac 
insufficiency from valvular disease, myocarditis, and pulmonary em- 
physema, (b) Local stasis is much less important, and has scarcely 
any part in renal pathology (Cohnheim). Berkmann (1859) described 
renal stasis and thrombosis of the renal veins occurring in the new- 
born or in nurslings after severe diarrhoea; when unilateral, there is 
renal pain, great albuminuria, some hsematuria, swelling of the kidney 
and decreased urine; most cases of bilateral thrombosis die from 
anuria and uraemia. Thrombosis of the cava, and pressure by large 
tumors may cause passive congestion in the renal veins. 

Pathology. — Anatomical changes result from slowing of the arterial 
flow, lessened arterial pressure, and to a less degree from venous 
hypersemia, which changes alter the integrity of the secreting renal 
structures, notably the glomeruli. In experiments, arterial insuffi- 
ciency causes initial glomerular alteration, while venous obstruction 
causes primary congestion in the medullary portion. 

Early Changes. — The kidney is swollen, dark red and firm, and its 
stellate veins are prominent. On section it expands beyond its close 
fitting capsule, which is readily stripped off. The organ is very vas- 
cular and may drip blood. The glomeruli are seen as dark red points 



792 DISEASES OF THE KIDNEY 

and the medullary bloodvessels are clearly denned. Microscopically 
the conspicuous changes are hyperemia, occasionally with punctate 
hemorrhages, fatty and cloudy degeneration of the epithelium of the 
tufts and convoluted tubules, escape of albumin into them, forming 
hyaline casts in the tubules, and finally some thickening of the vessels. 

Late Changes. — Prolonged stasis leads to greater atrophy of the 
secreting structures and to increase of connective tissue; this "cyanotic 
induration" has been rather overdrawn in clinical descriptions, but 
may result from extreme and protracted stasis. The kidney becomes 
pale and firm, the cortex shrinks, the capsule may become somewhat 
adherent, and connective tissue develops in the medulla. Micro- 
scopically, fibrillar connective tissue, thickening of Bowman's capsule 
and epithelial degeneration are found. 

Symptoms. — Aside from the causal heart or other lesion, and the 
signs of stasis in other parts, the urinary findings are of chief interest. 
The urine is decreased, and its amount follows directly the heart's 
activity. It is acid, dark, concentrated (specific gravity 1,025 to 1,030) 
and it has a lateritious sediment of urates and often of uric acid crys- 
tals. Albumin and globulin are present, usually in moderate amounts. 
Urobilin may be present. Microscopically a few leukocytes, epithelial 
cells and hyaline casts are found; granular casts are seldom found 
and should arouse suspicion of nephritis; red cells are usually con- 
sidered common, but Leube insists that they almost always indicate 
nephritis or infarction. 

Diagnosis. — The urinary findings are significant in association with 
the causal lesion; oedema begins in the legs; the nutmeg liver, dyspnoea, 
cyanosis and pulmonary stasis are present. The percentage of albumin 
runs parallel with the strength of the heart, increasing with its failure, 
or decreasing if digitalis or strychnine improve its action. If cardiants 
increase the urine, and if abundant albumin and casts still remain, 
there is probably coincident nephritis. (See Table pages 796 and 797.) 

The treatment is that of chronic valvular disease (q.v.). 



2. Infarction — Embolism. 

Though infarction may rarely occur from local disease of the renal 
arteries, acute or chronic valvular disease of the left heart is its pre- 
disposing cause. Sixty-six to 75 per cent, of all embolisms are renal. 
Stoppage of a renal terminal artery causes the well known wedge- 
shaped anaemic infarct in twenty-four to thirty-six hours; the local 
ischsemia causes fatty degeneration, necrosis, and a finely granular tran- 
sudation into the connective tissue and glomeruli. After a while fibrous 
substitution occurs with ultimate shrinkage and deformity. After 
repeated infarctions, the irregular " embolic contracted kidney" is seen. 
As in other infarctions, the process may be innocent (mechanical) or 
less commonly suppurative. 



AMYLOID DEGENERATION OF THE KIDNEY 793 

Symptoms. — In most cases there are no symptoms. Exceptionally 
a diagnosis is possible, based on (1) the valvular lesion; (2) sudden 
onset with fever; chills and vomiting; (3) lumbar pain and tender- 
ness, and (4) hematuria and albuminuria. 

There is no treatment. 



(D). AMYLOID DEGENERATION OF THE KIDNEY. 

Etiology. — The etiology of amyloid kidney is that of amyloid liver 
(q. v.); its three principal causes are ulcerative tuberculosis, protracted 
suppuration and inveterate syphilis. The most plausible theory is 
that toxins produce, either in the blood or in the organ involved, an 
albumin which is deposited in and about the bloodvessels. Amyloid 
kidney was first described by Rokitansky (1842) and its symptom- 
atology was developed by Wilkes, Todd and Traube. 

Pathology. — Amyloidosis seldom occurs in the kidneys without 
associated changes in the liver and spleen. To the naked eye the 
kidneys generally appear enlarged, weighing together even as much 
as 26 ounces (870 gm., Johnson); when amyloid degeneration or 
infiltration is slight, there may be no alteration in size or weight; in 
some cases the kidneys are large from coincident chronic parenchy- 
matous or small from interstitial nephritis. The capsule strips readily, 
showing a pale, smooth surface. On section the cortex is enlarged, 
glistening, waxy, and pale and its edge translucent; the glomeruli 
stand out as glistening points, and become brown when treated with 
Lugol's solution. Microscopically the amyloid substance can be seen 
clearly; it is so named because of its starch-like reaction, though 
chemically it is an albuminoid. It is either deposited from the blood 
in the small vessels, or more probably formed in situ, whence it is 
found especially in the glomeruli, then in their afferent vessels and in 
the straight vessels of the medulla. The renal interstitium is involved 
secondarily, and the epithelial cells never suffer directly, though the 
membrana propria may be affected and the cells may suffer secondary 
compression, degeneration and atrophy. As the changes indicate, 
amyloid disease cannot be classified with Bright's disease, though their 
association (v.i.) is not uncommon. 

Symptoms. — Its symptoms are variable, (a) Urinary symptoms 
are exceptionally absent (Rosenstein and Litten). The urine is gen- 
erally limpid and increased, but may be decreased when amyloid 
degeneration is associated with parenchymatous, or greatly increased 
when associated with interstitial, nephritis; some writers place rather 
undue importance upon variability in its amount. The specific gravity 
is 1,010 to 1,015. Albuminuria is usual, being absent only in those 
exceptional cases which invade the vasa recta and avoid the glomerular 
capillaries; albuminuria results from increased permeability of the 
glomerular vessels and may amount to 1 or 2 per cent. ; Senator has 
remarked that there is frequently a large amount of globulin in the 



794 DISEASES OF THE KIDNEY 

urine. There is little or no change in the solids as a result of the 
amyloid itself; indicanuria is not infrequent. Microscopically hyaline 
casts may be present and perhaps a few leukocytes and epithelia, 
but the sediment is scanty in most cases; the so-called waxy or amy- 
loid casts found in severe nephritides have no relation to amyloidosis 
of the kidney, (b) Cardiac hypertrophy, uraemia and retinitis do not 
occur in renal amyloidosis, except when it is associated with nephritis, 
(c), Amyloid degeneration of both the spleen and liver and sometimes 
also of the alimentary tract are associated in 66 per cent, of cases; 
these and the casual disease are necessary for diagnosis, (d) (Edema, 
and an&mia which is almost an actual cachexia, are usual in cases of 
diffuse developed amyloidosis. Hydrops of the serous sacs, especially 
ascites, is quite common though less so than oedema, and usually 
occurs as a late or terminal event. Differentiation (v. Table on pages 
796 and 797.) 

Prognosis. — Amyloid disease is generally incurable, though as 
stated under amyloid liver, light grades may recede. Amyloid of the 
kidneys in most cases runs its course in a year or less, particularly 
when associated with parenchymatous nephritis. Cases may endure 
for several, even fifteen years, but these are generally complicated by 
contracted kidney. 

Treatment. — Treatment consists chiefly of prophylaxis; with mod- 
ern surgical treatment, amyloid disease is less common than formerly. 
Early treatment of tuberculosis and syphilis decreases the percentage 
of amyloidosis; for the developed disease there is no treatment. 

(E). MALFORMATIONS OF THE KIDNEY. 
Malformations and Structural Anomalies of the Kidneys. 

To malformations and structural anomalies in general, but little 
clinical importance is attached. Complete absence or rudimentary 
development of both kidneys occurs only in unviable infants, 

One kidney, usually the left, may be absent or rudimentary, whereon 
the normal kidney vicariously hypertrophies; the enlargement may 
be mistaken for malignant disease, whence its removal is fatal. Before 
operation it is imperative, at least in doubtful cases, that cystoscopy 
be employed to determine the presence of two ureters or that a pre- 
liminary incision be made to ascertain that there are two kidneys. 
Two ureters may come from one kidney. Ballowitz collected 184 
cases in which one kidney was lacking; 61 per cent, occurred in males 
and in 63 per cent, the left kidney was lacking. According to Gerard, 
unilateral absence of one kidney is usually associated with unilateral 
malformation of the internal genitalia but this is not true in unilateral 
renal atrophy nor in cases where two kidneys fuse. 

Supernumerary kidneys, double kidney, deformation from lacing, or 
scoliosis, are of pathological interest only; 15 cases of supernumerary 



MOVABLE KIDNEY 795 

kidneys are recorded (Graser) and in two cases there were four 
kidneys. 

The "horse-shoe" kidney (ren arcuatus) due to the fusion of both 
kidneys, is fairly common. Errors in diagnosis are common especially 
if the kidney is dislocated, and are inevitable if the renal pelvis is 
inflamed or dilated. Cases are reported in which the ren arcuatus 
has been mistaken for a tumor and extirpated, obviously with fatal 
results. 

Movable Kidney. 

Congenital dislocation occurs twice as frequently in men as in 
women, and is usually left-sided, in which respects it differs from the 
acquired form. It frequently coincides with congenital anomalies of 
the genitalia and intestines, and is of more anatomical than clinical 
interest. The kidneys may lie one upon the other (dystopia renum 
cruciata), of which Chatelin could collect but 15 cases. The kidney 
may lapse into the pelvis. The ureters are sometimes quite short. 

Acquired dislocation, described by Rayer nearly a century ago, is 
much more common and important. It is variously called movable 
or floating kidney, ren mobilis seu migrans, ectopia renis acquisita, 
nephroptosis. 

Etiology. — (a) Sex; 88 per cent, occurs in women, as shown in 
Kuttner's collection of 667 cases ; Dietl claimed that women constituted 
99 per cent, of the cases, (b) Age. Most cases occur between the twen- 
tieth and fiftieth years. Comby reports 18 and Abt 5 cases in children, 
(c) The actual cause is disputed. The kidney is supported by the fat 
around it, the peritoneum in front of it and by its own bloodvessels. 
Among the alleged causes are; atrophy of the perirenal fat; the presence 
of a mesonephron (Gerard) surrounding the kidney to a variable extent; 
weakening of the abdominal walls by pregnancy and other causes ; alter- 
ations in the intra-abdominal pressure by malpositions of the uterus, e. g., 
prolapse (Landau) ; pressure exerted by corsets on the liver (Cruveilhier) ; 
congenital laxness of the supporting structures, in connection with 
which Stiller claims that the tenth rib is usually "floating" like the 
eleventh and twelfth ribs (costa fluctuans decima); tumors of the 
kidney, which drag it downward; trauma or sudden efforts, as in 
lifting. Several of these causes are also thought to produce enterop- 
tosis, in connection with which floating kidney is very frequently 
observed. 

Symptoms. — Symptoms are absent in many, probably in most cases; 
they may date from the time when the physician incautiously remarks 
upon the presence of "a floating kidney. " There are two main symp- 
toms, the subjective pain and the objective tumor. 

Pain. — Pain may be merely a dragging sensation or may amount 
to severe renal colic, which is said to result from stretching of the renal 
nerves; it may be lumbar, abdominal or may shoot toward the heart, 
thigh or sciatic region; it may occasion intercostal neuralgia, even on 



796 



DISEASES OF THE KIDNEY 



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DIAGNOSIS OF DIFFUSE DISEASES OF THE KIDNEYS 797 

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798 DISEASES OF THE KIDNEY 

the opposite side of the body. Pain may be constant or intermittent, 
mild or severe or like a crisis (v.i.). 

Objective Kidney Findings. — On bimanual examination with one 
hand over the kidney in front and the other pushing it up from behind, 
the findings vary; (a) frequently the kidney is not painful nor tender, 
but palpable, which condition has no significance especially in women; 

(b) the kidney may be movable, descending on deep inspiration, maybe 
to the navel, where it can be retained by pressure during expira- 
tion; movable kidney is found in 20 per cent, of women (Tuffier); 

(c) the kidney may be floating (the most extreme type), in which it 
may fall or wander to the lower abdomen or pelvis. In 76 per cent, 
of cases the right kidney is involved, in 11 per cent, the left, and in 
13 per cent, both kidneys (Kuttner); the right kidney has longer 
vessels, and the left renal vein is more firmly connected with the 
suprarenal vein and the pancreas. When the kidney is grasped a 
sickening sensation sometimes results as when the testicle is com- 
pressed. The tumor w smooth and is usually recognized by its shape. 
In rare cases the pulsating renal vessels are felt (v. Frerichs and Eich- 
horst). If not clearly felt when the patient is lying on the back, pal- 
pation is made in the standing posture or with the patient lying on 
the left side. Little confidence can be placed in percussion along the 
spine, though occasionally tympany can be found over the normally 
dull area along the spine occupied by the kidney; the renal dulness 
merges with that of the liver and spleen above and extends outward 
2.5 inches (6 to 7 cm.) on the left and 3.5 inches (8 to 9 cm.) on the 
right side. In thin subjects the sinking in of the back and the tumor 
in front may sometimes be clearly seen. In rare instances the kidney 
may be found in a hernial sac. 

Other Symptoms and Complications. — (a) The same train of neur- 
asthenic, hysterical or hypochondriacal symptoms are present as in 
enteroptosis ; Tuffier believes that these symptoms are causal rather 
than sequential. Nervous dyspepsia is particularly common. (6) 
Dietl (1864) described attacks of sudden severe pain and collapse 
known as " DietVs crises"; they are marked by fever, chill, vomiting, 
collapse, severe pain, sometimes with swelling and tenderness of the 
kidney, scanty urine containing blood, pus, uric acid and oxalates, 
and in some instances peritonitic manifestations; Dietl's theory that 
the kidney became "incarcerated" between the connective tissue and 
peritoneum is now abandoned; Gilewski maintains that the ureter 
is twisted, forming acute renal retention and hydronephrosis, and in 
one of Sutton's cases, the ureter was found twisted three times. Lan- 
dau holds that the renal vessels suffer torsion, and Mosler explains the 
crises by acute nephritis, ureteral stoppage or peritonitis, (c) Dilata- 
tion of the stomach is neither causal or sequential. It is only a co- 
ordinate and not at all a common coincidence, (d) Dysmenorrhea, 
constipation and enteroptosis are common complications. Colitis 
mucosa is reported by Morris. Compression or actual stenosis of the 
intestine, icterus, abdominal aneurysm by tugging through the renal 



ALBUMINURIA 799 

vessels upon the aorta, compression of the cava inferior and adhesions 
to the gall-bladder are rare (and questionable) sequences. Albumin- 
uria may occur periodically, on palpation of the kidney or when the 
patient stands (orthostatic type). 

Diagnosis. — The diagnosis is rarely difficult. The finding on biman- 
ual examination of the sensitive kidney-shaped movable tumor is more 
important than the inconstant subjective or ambiguous neurasthenic 
symptoms. Severe pain may be confused with a tabetic crisis, appen- 
dicitis or the passage of gall- or kidney-stones. The kidney may 
possibly be mistaken for some other movable tumor, as omental, 
gastric, intestinal, and gall-bladder tumors or corset liver. Morris 
has reported cases in which an enlarged gall-bladder has been mis- 
taken for movable kidney; both tumors are movable, may induce 
icterus or dyspeptic disturbances, and both may be attended by colic 
and a dull (or resonant) note over the tumor. Doubtful cases are 
usually determined by repeated examinations, perhaps under anaesthesia. 
Particular reserve is necessary in the diagnosis of left-sided floating 
kidney. 

Prognosis. — Death is an extremely rare occurrence, though it may 
result from " incarceration" and peritonitis. 

Treatment. — The patient should never be told of a movable or 
floating kidney, because the symptoms, chiefly the neurasthenic, may 
date from the diagnosis, (a) A rest cure may develop adipose tissue 
and relieve the nervous symptoms. (b) A well-fitted bandage, with 
padding to prevent renal descent, is excellent in many cases, (c) 
In obstinate and extreme cases, neurorrhaphy or nephropexy, as 
recommended by Hahn, is indicated. According to Czerny and Giess, 
82 to 85 per cent, are cured. Tuffier gives results of 163 cases as 
follows: absolute recovery 53 per cent.; improvement 30 per cent.; 
temporary improvement 5 per cent., and failure 12 per cent. Frank 
gives the results of Hahn's clinic as 70 to 80 per cent, complete recovery, 
15 to 20 per cent, decidedly improved, and 5 to 10 per cent, failures; 
the mortality was under 1 per cent. Nephrectomy is seldom indicated. 
(d) The crises are treated by morphine, reposition and later by 
operation. 



(F). ALBUMINURIA AND OTHER ANOMALIES OF RENAL 

SECRETION. 

I. Albuminuria. 

Albuminuria was discovered by Cotugno in 1770. It results (a) 
from leakage of albumin through the glomeruli and tubules (albumin- 
uria vera, renalis) or (b) from admixture of blood, pus, semen or fluid 
of tumors (albuminuria spuria). The genuine form will be first 
considered, and the spurious or accidental form later under pyuria 
and hematuria. 



800 DISEASES OF THE KIDNEY 

The most common albumin is serum albumin (or simply, albumin) 
with which serum globulin is frequently associated. 

Etiology. — (a) Its incidence in the diffuse renal diseases, the nephri- 
tides, amyloidosis and passive congestion has already been discussed. 
(b) Blood alterations are frequent causes; as (i) blood diseases proper 
as anaemia, leukaemia, pseudoleukemia, pernicious anaemia, scurvy, 
or purpura in which the poverty of the blood or toxins induce renal 
degeneration; (ii) toxaemic states, as the acute and chronic infections, 
in which "febrile albuminuria" (Gerhardt) evidences the renal degen- 
eration; this condition borders very closely on or merges into mild 
cases of acute nephritis; (iii) diabetes, icterus, and poisoning by 
lead, mercury, ether, etc. (c) Nervous maladies possibly act by lower- 
ing the local blood pressure, as epilepsy, exophthalmic goitre, migraine, 
and the psychoses, (d) Affections of the digestive tract, as intestinal 
incarceration, hepatic diseases, and lead colic may produce albumin- 
uria, (e) In the new-born, it was first noted by Virchow. It is almost 
regular in the first week or ten days of life (Ruge, Martin) and occurs 
with hyaline casts, urates and epithelium. It is hardly explained by 
change of metabolism or of circulation or by uric acid infarcts. Ribbert 
holds that it is due to imperfect development of the glomeruli. (/) 
Pregnancy is an etiological factor; it occurs in 40 per cent, of cases in 
the last few months of gestation (from increased tax on the kidneys, 
and from pressure) and in the same percentage after delivery (from 
effort and strain), (g) Is there a" physiological albuminuria 3 "? Var- 
ious types are described, as Pavy's cyclical albuminuria, which appears 
and disappears; intermittent albuminuria; adolescent albuminuria, 
in young anaemic subjects, often with vasomotor disturbances; ortho- 
static albuminuria, also termed postural or orthotic, which appears 
only when the subject stands. Some practitioners bring under this 
caption albuminuria after heavy eating, severe exercise, coitus, mental 
strain or cold baths. Certain clinicians as Senator, Bradford and 
Grainger Stewart, whose names alone carry weight, insist that thera 
is a physiological albuminuria, in which signs of nephritis, as casts, 
or cardiovascular changes are absent. The author regards every case 
of albuminuria as pathological; its cause may be an insidiously de- 
veloping nephritis, a receding nephritis, stasis, or maybe "consti- 
tutional/' as Martius calls it, but it is always a sign of glomerular or 
tubular lesion (see Prognosis), however slight it may be. The amount 
of albumin in this type rarely exceeds 0.4 to 0.5 promille (Senator). 

Detection. — The urine must be clear and acid; if turbid it should 
be filtered and if it then remains turbid it should be cleared by shaking 
with magnesia usta; it must be acidulated, if necessary, with acetic 
acid; if very concentrated, dilution with distilled water is advisable. 

1. Boiling Test. — A test-tube, two-thirds filled with urine, is held 
by its lower part and the upper layers are boiled. Albumin produces 
clouding, which may also result from phosphates and carbonates 
(dissolving when nitric acid is added), from balsams (dissolving in 
alcohol) and, it is said, from urotropin and formaldehyde. Nitric 



ALBUMINURIA 801 

acid should not be added before boiling, for a soluble acid-albumin 
may result. 

2. Nitric Acid or Heller's Test. — Urine, somewhat diluted, is placed in 
a test-tube or conical glass, and nitric acid is run under it by a pipette. 
The fuming or nitroso-nitric acid is obtained by heating nitric acid in 
which a small bit of wood is placed (part of the stick of a match). 
Albumin, globulin, mucin, and albumose are precipitated at once or 
after a few minutes at the contact point; albumose dissolves by heat- 
ing, the others do not. These tests are very satisfactory. 

3. Ferrocyanide Test. — To a test-tube half full of urine, 10 drops 
of acetic acid are added, which may precipitate uric acid, urates, 
oleoresins or nucleo-albumin (mucin). These are filtered out and one 
dram (5 c.c.) of a 10 per cent, solution of potassium ferrocyanide is 
added. A precipitate indicates albumin, globulin or albumose, which 
latter alone dissolves on heating. 

4. Acetic Acid and Salt Test. — Adding to the urine acetic acid to 
an acid reaction, and then an equal volume of saturated sodium chloride 
solution, precipitates albumin and albumose, but the latter dissolves 
on heating. The above tests detect albumin in dilutions as low as 
one part in 10,000. 

5. Spiegler's Test. — This should be used if more delicate tests 
seem necessary. Nucleo-albumin (mucin) is removed by adding 15 
drops (1 c.c.) of dilute acetic acid and filtering. To the urine is added 
a quantity of Spiegler's reagent (bichloride mercury 8, tartaric acid 4, 
glycerine 20, and distilled water 200,) when albumin or albumose 
develop in the contact zone. One part in 350,000 may be detected. 
Jolles' modification: bichloride 10, succinic acid 20, sodium chloride 
20, and 100 parts of distilled water. 

Globulin occurs chiefly in renal congestion, acute and chronic ne- 
phritis and amyloid degeneration. It dissolves in an excess of acetic 
acid. It is precipitated by boiling. Flocculi of globulin are thrown 
down, when 2 drops of dilute acetic acid are added to 50 c.c. (1.6 
ounces) of filtered urine diluted 10 times with distilled water. 

Nucleo-albumin (formerly called mucin) occurs in acute desquamative 
nephritis, icterus, poisonings causing necrosis of the renal cells, and 
regularly in catarrh of the urinary passages. It is precipitated by 
boiling and by acetic acid, and unlike globulin, does not dissolve in 
an excess of acetic acid. Shreds of mucus, voided with colic, have 
been observed by von Jaksch and Baumueller; the condition seems 
analogous to colica mucosa and spasmodic asthma. 

Peptone or albumose is of little clinical importance; the terms include 
albumins which do not coagulate by heat. When the urine is boiled, 
the albumin is precipitated and filtered out. Albumose in the filtrate 
causes clouding and precipitation on cooling. What Kuhne once called 
peptone is now termed albumose. (a) Bence Jones' albumose is 
rather a peculiar albumin than an albumose; described by him in ISIS, 
albumosuria has also been called Kahler's disease. Muffat (1905) 
collected 38 cases. Its significance is uncertain; it has been found 

51 



802 DISEASES OF THE KIDNEY 

in osteomalacia, and in multiple myeloma. It is precipitated by cold 
nitric acid, dissolves on heating and reappears on cooling, (b) Albumose 
may be found in various acute infections (meningitis, rheumatism, 
pneumonia), septicaemia, peritonitis, empyaema, in acute yellow atrophy, 
etc. Albumin in the kidney, bladder or urinal, may be converted by 
pepsin into albumose. 

Diagnosis. — The diagnosis of albuminuria is easily determined by 
the tests enumerated; blood or pus may give albumin reactions (acci- 
dental or spurious albuminuria, v. haematuria and pyuria). 

Prognosis and Treatment. — These are etiological. The outlook is 
not favorable, though not necessarily bad. In seemingly "physio- 
logical" cases, the condition of the heart must be watched and casts 
carefully looked for. In youth and adolescence albuminuria may be 
"physiological" but in middle and later life it is usually nephritic. 
Shattuck and Osier, however, hold that "albuminuria is more com- 
mon apart from Bright's disease than is commonly supposed, that it 
increases with advancing years, and that a small amount of albumin 
with finely granular casts of small diameter in those over fifty years 
of age is of small importance." Life insurance companies are sus- 
picious of "physiological" albuminuria, for figures show that it 
entails a death-rate which is double the average. Albuminuria is said 
to result solely from high arterial tension, but the author is inclined 
to regard these cases as incipient arteriosclerosis or contracted kidney. 
Hawkins reported a case in which albuminuria lasted, without any 
unhappy symptoms, for forty-three years after Bright had given a 
fatal prognosis. 

II. Hematuria. 

Etiology. — Like albuminuria, blood in the urine (haeinaturia) is 
only a symptom, and is observed in many diverse conditions, (a) It 
is most frequently renal, (i) General conditions may cause it, as intoxi- 
cations (by quinine, carbolic acid, turpentine, or salicylic acid), acute 
infections (of which malaria is the most common, acute exanthemata, 
particularly the hemorrhagic types) or the blood diseases (purpura, 
scurvy, haemophilia, leukaemia, and the anaemias), (ii) Other causes 
are local renal conditions, as trauma, vascular maladies (thrombosis of 
renal veins, infarct, aneurysm, varicose veins, arteriosclerosis, and 
rarely passive congestion); inflammation (acute, chronic, hemorrhagic 
and suppurative nephritis); rarely amyloidosis or parasites (distoma, 
filaria, nephrophages sanguinarius) ; tumors; tuberculosis; calculous 
ulceration and pyelitis ; sometimes floating and cystic kidney, especially 
after bimanual examination, (hi) Haematuria may be "idiopathic" 
or "essential" In some very rare cases it occurs in "apparently 
healthy kidneys," to which phrase there has been a just objection. 
This condition has been called renal epistaxis (Gull), angioneurotic 
haematuria (Klemperer) and renal purpura (Senator). M. L. Harris 
collected 18 cases in which simple nephrotomy gave relief. In Esh- 



HEMATURIA 803 

ner's series of 48 cases of unilateral renal hematuria, nothing was 
found at operation in 33 per cent., floating kidney existed in 12.5 
per cent., renal pelvic changes in 19 per cent., and diffuse renal dis- 
ease in 24 per cent, (b) It may occur from lesions in the lower urinary 
tract. The chief types of these lesions are stone in the ureter or bladder; 
ruptured varices anywhere in the urinary tract; stasis from liver cir- 
rhosis or thrombosis of the iliac veins; inflammation (pyelitis, ureteritis, 
cystitis, prostatitis or urethritis, sometimes called " Russian gonor- 
rhoea"); and tuberculous, malignant, or other ulcerations. 

Symptoms and Diagnosis.— Hemorrhage may be macro- or micro- 
scopic. The urine may be clear or turbid, red or smoke-colored. It 
is usually acid, but may be alkaline when there is copious vesical 
hemorrhage. The color is generally brighter when the urine is alkaline. 
Confusion with concentrated, icteric, carbolic, fuchsin, hematoxylin 
and senna urines is possible. The presence of blood is positively 
determined (a) by the microscope; the red cells remain normal for a 
long time in acid urine, but may become pale in dilute, and mulberry- 
form in concentrated urine; (b) by the spectroscope; if no red cells 
are present with positive spectroscopic findings, it indicates hemo- 
globinuria (v.i.); and (c) by chemical tests as Heller's (boiling with 
caustic potash, which throws down a rusty phosphate and hsematin 
precipitate), the Almen guaiac test (acidulating the urine and adding 
old turpentine and fresh guaiac) which gives a blue reaction (also 
produced by pus) and Teichmann's test (treating the sediment with 
sodium chloride and glacial acetic acid, slightly heating and cooling, 
when hsemin crystals are deposited). 

Diagnosis of the origin and cause of hematuria is often most diffi- 
cult, (a) In cases of renal origin, the blood is intimately mixed with 
the urine, as much with that first voided as with the last. The color 
is often that of water in which raw meat has soaked ("beef water" 
color). Clots are infrequent in renal hematuria, save from trauma, 
tumors, aneurysm, or varicosities. The red cells are seldom seen in 
rouleaux-form and, according to Gumprecht, are fragmented from 
action of the renal cells on the red disks ; this does not occur in vesical 
hemorrhage. If there is some other renal lesion, as nephritis, there 
is more albumin than the red cells would account for, and albumin 
is present after careful filtering; according to Goldberg, if there is 
albumin with a red cell count, by the hemocytometer, of less than 
3,000 per c.mm., the albuminuria is renal. Blood casts, granular casts 
and renal epithelium are indicative of renal origin, (b) Hsematuria 
originating in the pelvis and ureter is more often marked by clots and 
possibly by caudate epithelium, (c) Blood from the bladder is more 
apt to clot, and the last part voided is more bloody than the first. 
Other symptoms, as tenesmus, alkaline urine reaction and perhaps 
pieces of tumor, very often indicate a vesical origin, (d) Urethral 
hemorrhage stains most deeply the first urine voided. It must, always 
be borne in mind that the presence of blood may be accidental, from 
menstrual or other contamination. 



804 DISEASES OF THE KIDNEY 

Treatment. — The treatment is etiological and can be but briefly 
considered here. Rest, and sometimes morphine, are indicated. Aside 
from the local treatment of vesical disease, urethritis, and calculous 
pyelitis, tannic acid, ergotin and calcium chloride aa gr. v. t.i.d. may 
check bleeding. Aromatic sulphuric acid ttj?x, well diluted, is also 
given at three-hour intervals. Adrenalin solution 1 to 1,000 parts, 
given by the catheter, may stop vesical hemorrhage. In essential 
(idiopathic) renal hematuria, simple incision of the kidney is fre- 
quently efficacious. 

III. Hemoglobinuria. 

This is haemoglobin in the urine without hematuria. Though first 
described by Dressier (1854), most of the early accounts are English, 
from Harley, Dickinson, Gull, and Pavy. There are two main groups, 
the toxic, and the paroxysmal. 

Etiology. — The toxic form may follow transfusion of blood, injec- 
tions of glycerin, poisons organic and inorganic, as potassium chlorate, 
phosphorus, mercury, quinine (in malarial cases only), carbolic acid, 
carbon monoxide; it may also result from burns, severe icterus, pernic- 
ious anaemia, scarlatina, acute nephritis, Winckers disease in the new- 
born, and aestivo-autumnal malaria. The paroxysmal form, of which 
Gilman Thompson recently collected 206 cases, occurs largely in 
England, France, and Germany; 96 per cent, are males, chiefly 
between thirty and forty years of age. Cold seems to be the most 
important factor; exercise, excesses, or menstruation, may precipitate 
an attack. It is observed in horses after cold and exertion; haemo- 
globinaemia and haemoglobinuria appear, paresis of the hind legs 
develops and death results from disturbed circulation and respiration. 
In cattle and sheep epidemics occur in which Babes, Krogius and 
others have found a haematococcus. In the majority of human cases, 
hemoglobinuria is preceded by haemoglobinaemia, though genuine 
renal haemoglobinuria (without haemoglobinaemia) seems to occur in 
some cases of nephritis and from certain intestinal nematodes. 

Symptoms. — Symptoms occur only after destruction of at least 
one-sixth of the blood. After a chill, fever, lumbar pain which radiates 
to the legs, cyanosis, oppression and gastric symptoms, the urinary 
findings appear; the urine is dark and contains clumps of blood 
pigment, casts and epithelium stained with haemoglobin or methaemo- 
globin, albumin and sometimes oxalate of lime crystals and bile 
pigments. In most cases the haemoglobin is already altered to meth- 
aemoglobin, as shown by the spectroscope. There may be slight 
jaundice, oedema, or urticaria. The blood shows increased coagulability 
and diminution in the number and redness of the red cells, which do 
not form in rouleaux. There may be swelling of the liver and spleen 
from haemoglobin deposits in them. The paroxysm lasts one-half to 
several hours, and in the interval the general health is fairly good. 



HEMOGLOBINURIA 805 

The course is most chronic. No death is known from the paroxysm 
itself and very rarely from the disease. 

Treatment. — Prophylaxis in regard to colds and exertion may 
modify the attacks. Chovstek was able to abort attacks by giving 
nitrite of amyl inhalations. Warmth may modify the seizure. Mercury, 
iodides, adrenalin, calcium chloride and thyroid extract have been 
recommended. 

IV. Pyuria. 

Etiology. — (a) Pus may originate from pyelitis or pyelonephritis. 
It may occur intermittently as in pyonephrosis, or continuously as in 
calculous or tuberculous inflammations. The urine is usually acid in 
tubercle and colon bacilli infections; it is acid in proteus and in some 
infections ascending from the bladder; the staphylococcus may render 
the urine less acid than normal or alkaline (v.i. pyelitis). (6) Pyuria 
may result from cystitis; the urine may be acid or alkaline and con- 
tains ropy mucus, and triple phosphates. Pus is seen especially in 
the last part of the urine voided, (c) Urethral pyuria, which is usually 
gonorrhceal, is greatest in that part of the urine first evacuated, (d) 
Accidental pyuria occurs from leucorrhceal contamination, and is 
easily excluded by examining specimens obtained by catheterization. 
Under this heading may be brought pyuria from rupture into the 
urinary tract of appendicular, pelvic, or psoas abscesses; much pus 
is voided at first, but it gradually lessens and disappears. 

Symptoms. — The urine in pyuria is yellow-white, turbid, and has 
a sediment which is sometimes ropy and becomes gelatinous when 
caustic potash is added. The reaction is often ammoniacal, due to 
germs decomposing the urea, as the proteus, and some staphylococci. 
Gas may be voided with the urine (pneumaturia) ; this occurs partic- 
ularly in enterovesical fistula and in diabetic cystitis. Alkalinity 
was formerly thought characteristic of cystitic, and acidity, of pyelitic, 
pyuria, but this distinction has been dropped. Albumin is found, 
the amount of which in simple^ pyuria corresponds with the number 
of pus cells. Albuminuria may be absent if there are not over 6-800 
pus cells to the c.mm. It is less or may disappear when the urine 
is filtered. The question often arises whether the albuminuria is 
simply accidental or is combined with renal albuminuria, for instance, 
whether cystitis is coincident with contracted kidney. Besides con- 
sideration of the amount of urine, its specific gravity, cardiovascular 
findings, and retinitis, besides washing out the bladder and ureteral 
catheterization, a study of the characteristics of the pus cells and 
their number is of great value. Senator has shown that leukocytes 
coming from the renal parenchyma in nephritis, are mononuclear, and 
those from suppuration are polymorphonuclear. Goldberg found that 
when (a) there is more than 1 part pro mille of albumin in the clear 
urine, as determined by Esbach's method, with (b) 50,000 pus cells 
per c.mm. as determined by the hsemocytometer, the albumin is partly 



806 DISEASES OF THE KIDNEY 

renal. De Lint altered Goldberg's method by gravimetric determina- 
tion of the albumin; when there is one part pro mille of albumin, 
and less than 7,000 pus cells, the albuminuria is (a) renal, and (b) 
it results from the pus alone, when there are more than 40,000 pus 
cells; no conclusion can be drawn if the pus cells number between 
7,000 and 40,000 per c.mm. 

Treatment. — The treatment is that of the fundamental tuberculosis, 
calculus, pyelitis, cystitis, etc. Salol and urotropin'aa gr. x t.i.d. are 
excellent antiseptics for the urinary tract. 



V. Chyluria. 

The endemic or tropical form is found in Florida and South Carolina, 
Brazil, the Antilles, Zanzibar, India, Egypt, and Japan. It is due to 
the filaria, which was first recognized by Bancroft and Leurs in the 
scrotum, by Wucherer in the urine, and by Lewis in the blood. It 
enters the body by the drinking water in which mosquitoes have on 
their death liberated filaria embryos. The filaria plug the lymph vessels, 
which dilate and rupture in the kidneys, .as proven by Mackenzie's 
autopsy. They are found in the blood at night (see Animal Para- 
sites). The non-tropical forms are not understood and have rarely 
occurred in Europeans who have never been in the tropics; the rare 
autopsies have shown no marked renal alteration (Roberts). 

The urine resembles chyle, is weakly acid or neutral in reaction, 
may present a fatty, creamy surface and contains 2 to 10 per cent, 
albumin (serum albumin, globulin or albumose), cholestearin, lecithin, 
fat, and stearic and palmitic acids. Its specific gravity is normal. 
Sugar is seldom found. Microscopic findings are fat globules, leuko- 
cytes, sometimes red disks and sometimes the filaria parasites, usually 
in the fibrin clots, which sometimes form and occasion dysuria. 
Casts are never found. Chyluria is often intermittent; it occurs espe- 
cially at night and may be initiated by exercise and changes of posture. 
In some cases there is considerable free fat in the blood (lipcemia). 
Its course is chronic, covering months to years. Recovery is the rule, 
though death may occur from anaemia and marasmus. Treatment 
is unsatisfactory. Potassium picronitrate gr. -J t.i.d. is said to accelerate 
recovery. Prophylaxis regarding drinking water must be considered 
in the tropics. 

VI. Lipuria. 

Lipuria or adiposuria is symptomatic of (a) lipcemia, or fat in the 
blood. The clearest instance is after bone fractures, contusions of 
the liver, or after delivery in which fat enters the blood from the pelvic 
cellular tissue. Fatty foods, as cod-liver oil; acute yellow atrophy; 
diabetes; diseases of the pancreas, and various poisonings and tumors 



LITHURIA 807 

are possible causes. (6) It is also symptomatic of renal lesions (from 
fatty epithelial cells, degenerated tumors, or fatty pus cells). 

Under the microscope small fat globules are seen, which stain black 
with osmic acid, or red with the alcanna test. The fat may be saponi- 
fied by alkalis, emulsified by albumins or dissolved by alcohol, ether, 
xylol or chloroform. Lipuria is often simulated by bacteria or phos- 
phates, or by oil from catheters, suppositories, or greasy urinals. 



VII. Phosphaturia. 

Phosphoric acid is chiefly excreted in combination, mostly with 
sodium and potassium forming the alkaline phosphates, and with 
calcium and magnesium forming the earthy phosphates. The sodium 
exceeds the potassium, and the calcium is in excess of the magnesium 
salts. Phosphoric acid is chiefly derived from the food, but some is 
derived from decomposition of lecithin, nuclein, and protagon. It 
averages thirty to forty-five grains (2 to 3 gm.) daily. Amounts over 
one dram (4 to 5 gm.) or alteration of the normal relation of the phos- 
phorus to the nitrogen (17 or 20 to 100) are pathological. An exces- 
sive deposit which occurs in dyspepsia, is not synonymous with an actual 
increase. Phosphaturia may be observed in neurasthenia, pulmonary 
tuberculosis, diabetes (largely from the diet), acute yellow atrophy, 
leukaemia, and in ansemia. As much as two drams (7 to 9 gm.) daily 
have been reported by Teissier and Ralfe, who termed the condition 
diabetes phosphatides. Earthy phosphates may cloud the last part of 
the urine, which is mistaken by the laity for " spermatorrhoea. " The 
addition of an acid rapidly clears the urine. The diet, recommended 
for this condition, consists of meat, fish, bread, potatoes and apples. 
Coffee, nux vomica, arsenic, cod-liver oil, or ammonium benzoate (gr. 
x to xxx t.i.d.) are also given. 



VIII. Lithuria. 

No subject has occasioned more clinical absurdities than uric acid. 
It normally bears to urea a ratio of 1 to 70. Futcher has found a ratio 
in gout of 1 to 300 or 500 (v. Gout). It is deposited in larger amounts 
than normal when the urine is very acid and the mineral salts or pig- 
ments are decreased. An increased precipitation is far more common 
than an absolutely increased excretion of uric acid. The sediment 
is clearly seen as red granules resembling red pepper. Uric acid 
combines chiefly with ammonium and sodium, and less with potassium, 
lithium and calcium, which form urates (sedimentum lateritium) of the 
pink or "brick-dust" color so frequently seen in febrile urine and 
urine of high specific gravity or of excessive acidity. They are soluble 
when heated and precipitate on cooling. 



808 DISEASES OF THE KIDNEY 



IX. Oxaluria. 



Oxalates, first detected by Donne (1838) in the normal urine, amount 
to less than 10 mg. daily. Quantities larger than this daily are path- 
ological. Helen Baldwin, in Herter's laboratory, decided that they are 
not formed during normal metabolism; they must then be taken in 
with the food. The actual conditions of oxaluria are in doubt. It 
has been observed in gout, emphysema, dyspepsias (especially in hyper- 
acidity and increased intestinal putrefaction), neurasthenia, icterus 
and diabetes. Oxalates occur as octahedral and dumb-bell crystals, 
which according to Klemperer occur in 50 per cent, of renal calculi. 
Cantani and others maintain that oxaluria is associated with nervous 
depression, irritability, lassitude, hypochondriasis, lumbar pain, sweats 
and nervous dyspepsia, though the concensus of opinion is against any 
definite clinical picture or diathesis. Klemperer has recently advised a 
diet of meat, fat and vegetables (except spinach and cabbage); he 
excludes milk and eggs and administers magnesium sulphate 5 SS once 
daily. Nitromuriatic acid ttj^j with tincture of nux vomica tt£x is an 
old and excellent empirical treatment. 

X. Indicanuria. 

Potassium indoxylsulphate is usually present in small amounts in 
normal urine. It is colorless as a rule, but may be voided blue or 
actually give a violet hue in alkaline urine. When acid or some 
oxydizing substance is added, it decomposes and frees indigo. The 
steps in its production are as follows: the action of the pancreatic 
juice on albumins produces indol, which is absorbed, oxydized in 
the tissues to indoxyl and unites with potassium sulphate to form 
potassium indoxylsulphate. Its absence in some pancreatic diseases 
has been discussed. It has been rarely found in urinary calculi. It 
is increased in cachexia? in which albuminous substances are decom- 
posed, in intestinal obstruction particularly of the small bowel, and in 
carcinoma, suppuration, and peritonitis. Boiling the urine and adding 
nitric acid, as in the ring test for albumin, gives a blue ring; adding 
half a dram (2 c.c.) of chloroform and shaking brings down the violet 
or blue-stained chloroform. 



XI. Other Anomalies. 

Alkaptonuria was discovered by Baedecker. It is a crystalline, 
aromatic body, probably derived from proteid decomposition, whose 
chief clinical significance is that (a) it reduces Fehling's solution, 
thereby simulating glycosuria, though it is negative to polarization and 
fermentation tests; and (b) it imparts to the urine a dark brown color, 



PYELITIS 809 

usually apparent only after it has stood or after caustic potash is added 
(alkaptonuria by derivation means urine which "absorbs" an "alkali" 
freely). Adding a drop of a very dilute solution of ferric chloride 
causes a dull green color which at once disappears. It is said to be 
homogentisic or uroleucinic acid. Sometimes it occurs as a familial 
affection. Garrod collected 40 cases, 73 per cent, of which were 
males; in 32 congenital cases, 19 of them occurred in 7 families. Vir- 
chow (1866) described a case of ochronosis, a discoloration of the 
cartilages and ligaments. Osier described 2 cases associated with 
alkaptonuria, making in all 9 cases in the literature; it may occur 
with pigmentation of the face, chronic arthritis and deformation of the 
lumbar vertebrae. 

Hydrochinon, from carbolic acid poisoning, may cause a somewhat 
similar discoloration. 

Hcematoporphyrinuria, discovered by Hoppe-Seyler, imparts a dark 
color to the urine. It occurs in pulmonary tuberculosis, rheumatism, 
intestinal hemorrhage, sulphonal and lead-poisoning, etc. Hsemato- 
porphyrin resembles hsematin, save that it contains no iron. 

Acetonuria is of clinical importance, chiefly in diabetes (q.v.). 

For fuller details the reader may consult works on clinical diagnosis, 
such as the recent treatises by Simon, Emerson and others. 



(G). PYELITIS— PYELONEPHRITIS— SUPPURATIVE NEPHRITIS. 

Pyelitis. 

Pyelitis and pyelonephritis are inflammations of the pelvis, and pelvis 
and kidney respectively. They were first described by Rayer. 

Etiology. — Pyelitis is almost invariably mycotic. The kidneys 
usually eliminate bacteria without injury to their structure but when 
the general vitality or the local resistance of the kidneys is lowered, 
inflammation of the pelvis or of the kidney may result. Various 
bacteria (v.i., Suppurative Nephritis) may be found, including the 
tubercle bacillus and other organisms, (a) Foreign bodies, as large, 
hard, or sharp calculi, less often cancer or tubercle, and still more rarely 
parasites, promote infection, (b) Ascending infections from the lower 
urinary tract are peculiarly dangerous when associated with urinary 
obstructions, as urethral stricture, hypertrophied prostate, or perhaps 
the pressure of a pregnant uterus. When the bacteria which produce 
cystitis cause decomposition of urea, the ammonia evolved acts as an 
additional eroding factor. According to Rosving, certain streptococci 
act in this way, but not the tubercle or colon organisms. Infection 
usually ascends from cystitis along the ureters, producing ureteritis, 
then pyelitis and perhaps a pyelonephritis, but it may reach the kidney 
along the lymph vessels, the microbes entering through erosions in 
the vesical mucosa. James Goodhart has shown that 50 per cent, of 
cases with obstruction to the flow of urine die of renal suppuration. 



810 DISEASES OF THE KIDNEY 

(c) Infection may be hoematogenous as in typhoid, the exanthemata, or 
in the intestinal catarrhs of infancy, (d) Less common factors in- 
clude traumatism, extension by contiguity from neighboring inflam- 
mations, as pyelonephritis (pyelonephritis is usually an ascending 
process, in which the kidney is secondarily involved, and only rarely 
is it a process descending from the kidney to the pelvis), toxic factors, 
as acrid, irritating diuretics such as turpentine, and hemorrhagic 
diseases, as black measles or scurvy; cold, venous stasis, and diabetes 
are somewhat predisposing factors ; arteriosclerosis promotes the form 
of pyelitis described by Ollivier, which is attended by hemorrhage 
and the formation of fibrin coagula. Pyelitis is most prevalent in 
males and in adults. 

Pathology. — Pyelitis may be acute or chronic; solitary or combined 
with cystitis; catarrhal, suppurative or ulcerative; unilateral or less 
often bilateral. Acute catarrhal forms present all the characters of 
mucous membrane inflammation, as redness, oedema, desquamation, 
formation of mucopus and minute ecchymoses. Chronic forms show 
grayish to reddish-brown pigmentation and thickening. In any form, 
croupous or diphtheritic inflammation or even gangrene may develop. 
Urates and triple phosphates may precipitate. Small cysts may form 
in the pelvis or ureter; this is caused by retention or perhaps by 
sporozoa; the small lymph nodes may enlarge, and in rare cases the 
epithelium may hypertrophy and thicken, causing cholesteatoma 
(y.i., issues). 

Symptoms. — (a) There are no certain symptoms in the rare cases 
in which a suppurative nephritis descends to the pelvis. (6) In the 
ascending type, early vesical symptoms antedate and often obscure 
the pyelitis, (c) The symptoms are most clear in primary pyelitis from 
calculus or from acute hematogenous infection. 

Pyuria is the chief symptom. The amount of pus is usually pro- 
portionate to the albumin (v. Pyuria). Its amount varies as well as 
its constancy; when the ureter is obstructed, pyuria is suspended, and 
when the obstruction is removed the pus escapes in increased amounts. 
Polyuria and a low specific gravity are usual in chronic cases; the 
urine may be doubled or tripled in amount, simulating diabetes 
insipidus; polyuria results from decreased absorption of water from 
the medullary portion or from compensatory hypertrophy of the 
sound kidney, or sometimes of the heart. In acute cases the urine is 
decreased. There may be other urinary findings. The urine is 
usually acid but quite often alkaline (from coincident or causal cystitis, 
or from bacteria decomposing the urea). It is often cloudy. It is 
true that large, caudate, club-like epithelial cells, often overlapping 
each other like shingles, are present in moderately severe pyelitis, 
but they may occur, though less frequently, in ureteritis and cystitis. 
When pyelitis extends to the papillae or higher (pyelonephritis), cylin- 
drical plugs of pus cells, epithelium, but chiefly of cocci, are seen 
(Fischl). Red cells (calculus), triple phosphate or uric acid crystals, 
fibrin (croupous or diphtheritic pyelitis), and various bacteria (perhaps 



PYELITIS 811 

tubercle bacilli) may occur. Pain over the kidney is usually dull, 
but in acute cases may suggest stone. There is a desire — probably 
reflex — to urinate frequently; this symptom may lead to an erroneous 
diagnosis of cystitis. Fever and rigors are not uncommon, especially 
in severe calculous or tuberculous types or those invading the kidney 
substance. Temperature is sometimes sudden and high ("irritative") 
and at other times is intermittent from septic absorption. 

Complications. — (a) There may be extension to the renal substance 
(pyelonephritis) and it may be reduced to a pulpy inspissated and even 
calcified mass, (b) Prolonged inflammation may lead to fibrosis of 
the kidney (Ackermann, Albarran); this is known as the "ascending 
contracted kidney. 1 " (c) Plugging of the ureter may occasion distention 
of the pelvis by retained urine (hydronephrosis) or pus (pyonephrosis), 
both of which conditions will be described below, (d) Anuria, de- 
scribed by Morgagni and later by Israel, is occasioned by reflex sup- 
pression of the sound kidney, or by extensive lesions in both kidneys. 
(e) Amyloidosis may be a complication. (/) Intoxication may occur 
by bacterial toxins and renal inadequacy. The condition resembles 
ursemia in some respects, but oedema, retinitis, and convulsions are 
absent. Senator described a dyspnoea like that of diabetic coma. 
Treitz and v. Jaksch believe that intoxication results from absorption 
of ammonia (ammoniamiia) from decomposed urea, (g) Perforation 
outward causes the paranephritic abscess (v.i.). In some cases an 
interesting condition called "spinal paraplegia" has been described; 
though it was once considered reflex, it probably results from an 
ascending neuritis. 

Prognosis. — The prognosis is influenced by the basic infection 
(whether simple, tuberculous, or calculous) and by the complications 
as described. In acute cases the outlook is generally good. Chronic 
cases without much necrosis may last many years and may even recover. 

Diagnosis. — Much depends on careful analysis of pyuria (q.v.). 
Cystitis may be confused with as well as combined with pyelitis. Their 
differentiation is often difficult from examination of the urine alone; 
the albumin and pus correspond in both, and possibly there is rather 
more albumin in pyelitis; no absolute reliance can be placed on the 
reaction, acidity, or alkalinity occurring in either condition, though 
pyelitic urine is probably more often acid. The tailed, clubbed, or 
shingle-like epithelia are more common in pyelitis, though not pathog- 
nomonic. Von Bergmann's method consisted of thorough vesical 
irrigation and then gentle compression of the suspected kidney to 
force into the bladder, and thence into the catheter, pus or cells; 
pain over the kidney and extending downward is significant; the 
only certain method is cystoscopy and ureteral catheterization. In 
nephritis the urine contains more albumin than is explained by the 
pus, though the amount may be slight in interstitial nephritis; the 
leukocytes are mononuclear and the presence of casts, cardiovascular 
changes, and the results of cryoscopy are usually decisive. 



812 DISEASES OF THE KIDNEY 

Treatment. — Prophylaxis involves care in the use of catheters, or 
irritating diuretics, the expectant treatment of gonorrhoea, etc. 
Water, milk and mineral waters should be used freely to flush out the 
urinary tract. Pain is relieved by hot applications to the kidney, 
and by giving five grains of powdered nutmeg; opium is seldom 
indicated. For pyuria, salol and urotropin aa gr. x p.c. are most 
efficient; the salol somewhat influences the pain. Methylene blue 
gr. j to ij, t.i.d. may be also given, but digestive disturbances must be 
watched for. Potassium chlorate gr. x to xx t.i.d. may lessen am- 
moniacal fermentation but may cause intoxication. These remedies 
are superior to lead acetate, sandal oil, or turpentine. Surgical inter- 
ference may be necessary when ureteral drainage is incomplete. Ne- 
phrotomy is the best operation, nephrectomy being seldom indicated. 



Suppurative Nephritis. 

Its etiology is partly that of pyelitis. The microorganisms encoun- 
tered are the staphylo-, strepto- and pneumococcus, Bacillus coli, gono- 
coccus, proteus, typhoid and tubercle bacillus, and actinomyces. (a) 
The embolic form results from suppurative processes elsewhere and 
represents merely one phase of septicopyemia of more pathological 
than clinical interest. The suppurative foci are nearly always bilateral 
and are chiefly cortical; the glomeruli are filled with microorganisms 
and, as the foci enlarge, they show as yellowish areas through the 
cortex; some deposits may also occur in the medulla; the kidneys 
are enlarged and lax. Clinically, pyuria, hematuria and cylindruria 
are seldom seen, and a diagnosis can seldom be made; anuria or olig- 
uria may result from multiple glomerular involvement, (b) The 
ascending type is essentially a cystopyelonephritis, which has been 
already described, and forms the so-called " surgical kidney"; infec- 
tion and urinary obstruction are its usual antecedents; pyuria, poly- 
uria and albuminuria its usual symptoms; and suppuration in the 
medullary rays its usual anatomical evidence; very rarely necrotic 
renal tissue is evacuated, (c) Suppuration of the kidney may result 
from its invasion by contiguity from adjacent pus foci, as appendicular, 
peri-uterine or vertebral foci; much pus may be voided at once with 
later gradual cessation of the pyuria. 

The diagnosis is always uncertain, save when sequestra come away, 
the prognosis always ominous and the treatment always expectant 
and surgical. 

(H). PERINEPHRIC ABSCESS. 

A distinction is sometimes made between perinephritis, inflammation 
of the fibrous capsule, and paranephritis, inflammation (suppuration) 
of the fatty capsule and surrounding tissue. 



PERINEPHRIC ABSCESS 813 

Etiology. — (a) The most common cause is suppurative disease of 
the kidney, as pyelitis, pyelonephritis, pyonephrosis (v.i.), and tuber- 
culosis, from which extension occurs by actual rupture or along the 
blood or lymph vessels, (b) Extension by contiguity may occur from 
vertebral caries, appendicular, pelvic or pancreatic suppuration, liver 
abscess, cholecystitis or even from the lungs and pleura, (c) It may 
result from trauma plus infection, (d) The so-called idiopathic cases, 
once attributed to cold, are probably embolic. Most cases occur in 
persons between thirty and forty years of age, and 70 per cent, occurs 
in males. 

Symptoms. — (a) The onset is acute, with a rigor and sudden tem- 
perature in the embolic (so-called primary) cases, but it is insidious 
in the secondary group. (6) Fever of a continuous or remittent type 
is usual, though it may be absent in some cases, i. e., absence of fever 
does not exclude suppuration, (c) Pain and tenderness are experienced 
over one kidney, somewhat more often over the right than the left. 
Sometimes, though seldom without coincident involvement of the 
kidney itself, pain shoots along the ureter to the pubes or thigh. To 
relieve tension the patient frequently lies on the back with the knee 
flexed and the thigh rotated outward. It may be here remarked, 
though we are discussing suppuration about the kidney (paranephritis) 
that pain may arise from simple inflammation of the fibrous capsule 
(perinephritis); this is relieved by simple nephrotomy, (d) Local 
findings may be marked or absent. In some patients there are lumbar 
adema, redness and swelling. The physical signs anteriorly are seldom 
marked, as suppuration usually occurs behind the kidney. The sur- 
geon finds at operation a diffuse phlegmon, and less often diffuse 
serous infiltration or circumscribed abscess; the pus may be odorless; 
it may smell of urine when the abscess has arisen from perforation 
outward of a pyelitic lesion ; a f secal odor results from infection (with- 
out perforation) from the bowel or from appendicular abscess. Ne- 
crotic fat and sometimes altered blood are voided, (e) The urine is 
negative, unless there are (i) a pyelitic origin and (ii) rupture of the 
abscess into the urinary tract. (/) The chief complication is rupture, 
which occurs in about a quarter of the cases; in 15 per cent, it occurs 
upward (Kuster), into the lungs and pleura, and in 8 per cent, it is 
downward, chiefly into the intestine. Burrowing to the peritoneum, 
groin, pelvis, or perineum may follow; according to Gerota, it occurs 
along the ureter toward the pelvis, when the abscess is anterior to 
the renal fascia and toward the lumbar region or iliac fossa when the 
abscess is behind the fascia. Amyloidosis may result from neglected 
or obscure cases of paranephritis. Serous pleurisy, subcutaneous 
emphysema, compression of the portal vein, icterus, and septicaemia 
may result. 

The course averages two to four weeks, though a longer duration 
is not uncommon. 

Diagnosis. — Diagnosis depends on (a) local pain, (b) oedema or 
swelling, (c) fever and (d) exploratory aspiration. Lumbago causes no 



814 DISEASES OF THE KIDNEY 

serious confusion. Other affections causing occasional confusion are 
psoas abscess, appendicular abscess behind the kidney or rupture 
downward of empyema though these are more often etiological factors 
than separate questions for differentiation. 

The only treatment is incision and drainage. In the cases of Schede 
and Schmieden complete recovery occurred in 73 per cent. 



(I). HYDRONEPHROSIS. 

Definition. — Hydronephrosis is a sac-like dilatation of the pelvis 
and calices, with accumulation in it of a watery fluid; obstruction to 
the urinary flow is its cause and atrophy of the renal substance is its 
result. It was first described by Tulp (1674) and named by Rayer. 

Etiology and Pathology. — There are two forms, the congenital and 
acquired, (a) The congenital form is most often due to anomalies 
in the ureters ; these include atresia, stenosis, valve formations, twists, 
compression by peritonitic bands, vestiges of Miiller's or Gartner's 
ducts, abnormal bloodvessels, imperfect insertion into the bladder, or 
insertion too high into the pelvis, in the lower part of which the 
urine accumulates. Of the latter form the author has seen two cases 
in young men and J. B. Murphy has observed four others. When 
there are double ureters, one may end blindly in the bladder wall, and 
dilating, may compress its fellow of the same side. In some few cases 
no obstruction is apparent. Hydronephrosis may occasion dystocia 
and is rather commonly associated with other congenital malformations ; 
65 per cent, of congenital cases are bilateral (Roberts), (b) The 
acquired form may be bilateral or unilateral, depending on its cause. 
This may, in rare cases, be in the kidney itself (Rayer, Chopart, Chris- 
tian Fenger), producing partial hydronephrosis. Enumeration of all 
possible causes of obstruction is unnecessary; one or both ureters 
may be compressed by malignant pelvic growths, as uterine cancer, 
and this in part explains the large proportion (67 per cent., Newmann) 
of bilateral hydronephrosis which occurs in autopsy figures; in clin- 
ical cases 62 per cent, are unilateral (Roberts). Ureteral obstruction 
may arise from calculus, tumors, tuberculous detritus, ulceration, 
cicatrization, floating kidney, or rarely clots from trauma or parasites. 
Large sacs are usually caused by affections of the ureter. Other 
possible types are obstruction from urethral stricture, enlarged pro- 
state or more rarely phimosis and atresia of the hymen. 

As Cohnheim contended, a slow development with intermissions is 
more potent in the production of large sacs than is acute obstruction, 
for slow compression permits more continued renal secretion. 

The results of urinary accumulation are (a) distention of the pelvis, 
(6) flattening of the papillae, (c) atrophy of the renal tissue, though some 
normal tissue usually remains, and (d) the formation of a fibrous sac. 

Symptoms. — The chief finding is a fluctuating renal tumor, (a) It 
is located at first in the renal region but later assumes an abdominal 



HYDRONEPHROSIS 815 

importance, (b) Its size varies in different cases, being largest when 
the ureter is obstructed and in slowly developing cases it may be as 
large as the head, and even simulate ascites; Peter Frank mentions 
a case in which it contained 60 quarts, (c) It may in the same case 
vary from time to time; this is known as intermittent hydronephrosis, 
and its chief causes are valve formation, stenosis or abnormal insertion 
of the ureter into the pelvis. The amount of urine is (i) normal from 
hypertrophy of the sound kidney, (ii) decreased in bilateral disease 
or from increased pressure in the diseased kidney, lessening the secre- 
tion from the sound kidney (Israel) ; or (hi) , when the sac evacuates, 
suddenly very abundant, and then the tumor disappears; this point 
is often volunteered in the patient's history. The author has seen 
hsematuria and renal colic occur in hydronephrosis due to an insertion 
of the ureter high up in the renal pelvis, (d) Its form, on bimanual 
palpation, is irregularly oval; in moderately severe cases the kidney 
itself may be palpated as well as its irregularly protuberant calices. 
(e) Sometimes the dilated ureter can also be felt. (/) The ballottement 
renal is a repercussion shock obtained by tapping the tumor with 
fingers of one hand, while the other is spread broadly over it. (g) 
Small tumors are covered by the colon, which imparts a modified tym- 
panitic note on percussion. Distention of the colon by air or gas brings 
out tympany over the tumor. Very large sacs push the colon aside. 
The ren saccatus may develop in a floating or horseshoe kidney, (h) 
Its contents are albumin, paralbumin, mucus, urea, uric acid and other 
urinary constituents, which are usually absorbed only after a long time. 
Diagnostic puncture is not always safe, (i) Sometimes it is tender 
from tension of the capsule; pain may also arise from torsion of the 
ureter, (j) Complications include rupture, infection (pyonephrosis), 
left ventricle hypertrophy, and anuria or uraemia if both kidneys are 
implicated. 

Diagnosis. — Diagnosis is quite easy (a) by recognizing the cause, 
if possible, as stone or tumor; (b) by careful bimanual palpation and 
(c) by cystoscopic proof that urine does not flow from one ureter. 
Differentiation concerns especially — 

1. The Exclusion of Other Renal Tumors. — (a) Pyonephrosis, a dilata- 
tion of the pelvis and calices by purulent fluid (instead of water-like 
fluid as in hydronephrosis), is caused by obstruction plus infection 
(especially from pyelitis with obstruction). It occasions the same 
kind of tumor as to location and physical examination, but presents 
some other features; it is generally smaller and more irregular than 
hydronephrosis; its walls are thicker and more tender, for infection 
is superimposed on obstruction ; there is more renal necrosis ; systemic 
septic symptoms prevail; its contents are pus, pulpy detritus, triple 
phosphates, bacteria, disorganized blood, fat, cholestearin, foetid am- 
monium compounds and even gas. Puncture is always dangerous, 
in doubtful cases more so than operation. Its prognosis also is clearly 
more unfavorable, (b) Cystic kidneys (q.v.) are very difficult (or 



816 DISEASES OF THE KIDXEY 

impossible) to differentiate, (c) Malignant renal growtJis, and (d) 
echinococcus, will receive consideration below. 

2. Other Abdominal Tumors. — (a) Ovarian tumor is connected with 
the uterus, grows upward, and may be associated with changes in 
the mammary glands and genital functions. Ovarian tumor with a 
long pedicle may deceive, but it pushes the csecum backward. The 
dulness is greater, though in large renal sacs the colon is pushed aside. 
The slight respiratory excursion and ballottement in hydronephrosis is 
of quite secondary diagnostic value. Confusion is very likely to occur 
when hydronephrosis develops in a floating kidney. Exploratory 
puncture is an unsafe procedure; when made, the fluid from ovarian 
cysts shows a high specific gravity (1,020); much paralbumin is 
present, also cylindrical epithelium, colloid or chocolate-colored ma- 
terial and of course no urea. Under narcosis the entire hand may be 
introduced into the rectum or colon to determine the point of origin 
of the tumor, though this method is severe, and is seldom necessary. 
(b) Ascites and pregnancy are readily differentiated, (c) Encapsulated 
peritonitis may be harder, but the urinary conditions and sac-like 
distention are usually decisive, (d) Splenic and hepatic tumors are 
more flat on percussion, encroach more upon the lungs and are above 
or anterior to the gas-distended colon. In a renal growth a furrow 
and tympanitic loop of bowel may lie between it and the liver or spleen. 

Prognosis. — The prognosis is generally unfavorable, as the cause 
is often inaccessible or the process well advanced. The prognosis is 
better in cases of renal stone than in cancer or in the generally inviable 
congenital forms. The course is often protracted and intermittent. 

Treatment. — Treatment is surgical. Nephrotomy is indicated, 
while nephrectomy is generally considered bad surgery since Ayrer 
and others have shown that some sound renal tissue nearly always 
remains. For the same reason ligature of the renal vessels should be 
avoided (Nicolai). The mortality resulting from nephrectomy for 
hydronephrosis is 5.7 per cent., for pyonephrosis 15.3 per cent. (Schmie- 
den); Rosving reports per cent, and 19 per cent, mortality in 
his cases of nephrotomy for hydro- and pyonephrosis, respectively; 
34 per cent, of his cases recovered completely, 27 per cent, recovered 
though with fistula, and secondary operation was necessary in 20 per 
cent. Fenger advised conservative operations, especially in partial 
hydronephrosis. Reference should be made to surgical treatises for 
details of operations on the ureter, excision of the pelvic sac, etc. 
Caspar and Kummel maintain that the phloridzin and cryoscopic 
tests are of great value in determining which side is involved, by test- 
ing the urine obtained from each ureter by ureteral catheterization; 
Israel has a very different opinion, as has Rosving, who prefers to 
cut down on both kidneys before extirpating either one. 



RENAL CALCULUS (NEPHROLITHIASIS) 817 



(J). RENAL CALCULUS (NEPHROLITHIASIS), 

Etiology. — Stone in the kidney or its pelvis results from deposition 
therein of the solid constituents of the urine. It is probable that stone 
formation is due to bacteria. The kidneys usually eliminate bacteria 
without changes to themselves, but sometimes bacteria, especially the 
colon bacillus (Schmorl), form the nucleus of stones. Ebstein, Moritz, 
Mendelsohn and others have shown that an albuminous cement sub- 
stance is found even in very slight urinary deposits or renal sand. 
Renal stone has been known since the time of Hippocrates. 

The predisposing factors are obscure, (a) A sedentary life and over- 
indulgence in food and alcohol are apparently predisposing factors. 
Galen noted the coincidence of gout and renal calculus. Stones are 
said to be uncommon in very active persons. (6) Most cases occur 
in persons between thirty and sixty years of age, though they may 
develop in early youth or old age, in which extremes of life vesical 
calculus is more common, (c) Seventy-five per cent, of cases are in 
males. Stones are passed more easily, and, therefore are possibly less 
often detected, in women, (d) Renal calculus occurs most frequently 
in Asia and there are certain foci, more of them in Europe than in 
America, where it is particularly frequent, as central Russia, Holland, 
Italy, Altenberg, Munich, Hungary, Scotland, west France and south- 
east England, (e) Other possible factors are heredity, which is espe- 
cially a factor in formation of uric acid and cystin calculi; paraplegia, 
(Muller reported 10 cases of spinal fracture with calculus formation); 
and foreign bodies in the renal pelvis, as blood clots from trauma, 
and such parasites as the distoma. The older classification of primary 
and secondary calculus has been abandoned. 

Chemistry and Pathology.— According to their size, these urinary 
deposits are spoken of as sand, gravel or stones; sand and gravel 
nearly always consist of uric acid or its salts. They may range from 
the size of a pea to that of a hazel-nut. The heaviest recorded stones 
weighed nineteen and thirty-six ounces. Though they are most often 
round, oval or cylindrical, they may be dendritic or coral-shaped. 
Sometimes they are facetted. A number of them may exist, perhaps 
15 or 20; in rare cases 1,000 to 2,000 may be found, (a) The stone 
caused by uric acid and urates (described first by Scheele, 1776) is 
the most common form, constituting 66 per cent, of renal stones. It 
is hard, smooth or slightly uneven, sometimes facetted or lamellated, 
and consists of uric acid, ammonium and sodium urates, urinary 
pigment, and a small amount of xanthin. Its broken surface is amor- 
phous. Its color is yellow, red, or brown, depending on the amount 
of urinary pigment. It may contain some oxalates and phosphates. 
Under the microscope needles are seen. Uratic calculi turn carmine 
red on adding nitric acid and ammonia. They dissolve in caustic 
potash. They are deposited in acid urine, but the exact reason for 
this is not known; the normal sodium urate may lose part or all of 

52 



818 DISEASES OF THE KIDNEY 

its sodium by action of the alkaline phosphates, so that free uric acid, 
and the less soluble bi- and quadriurates are formed; Roberts and 
Klemperer consider a decrease of the urinary pigments of great im- 
portance; disturbed metabolism or indigestion may occasion uratic 
deposits, though little is known of the "uric diathesis." (b) Oxalate 
stones (Fouccoy and Vauquelin) are next in frequency; Klemperer 
holds that oxalates occur in even 50 per cent, of cases. They are very 
hard, rough, warty or prickly (the mulberry calculus); for this reason 
they cause more pain and hematuria than the uratic stones and are 
more often removed surgically. They are usually single and gray, 
but may be dark-colored from the bleeding they induce. Lamellation 
is never observed. Uric acid, calcium carbonate or xanthin may also 
enter into their composition. No effervescence occurs on adding 
acetic acid, unless carbonates are also present. They dissolve in 
mineral acids, and oxalate of lime crystals gradually precipitate on 
the addition of ammonia. Oxalates precipitate from acid urine, (c) 
Phosphatic calculi (Bergmann) are formed in alkaline or neutral 
urine. They are usually calcium salts, but if the urine is ammoniacal, 
triple phosphates may be formed. Admixture of bacteria, calcium 
carbonate and xanthin may be noted; phosphatic stones are small, 
soft and clay-colored. They are infrequent and usually only form a 
coating to calculi of other composition, (d) Other forms are rare. 
Calculi of (i) calcium carbonate, and more rarely ammonium or magne- 
sium carbonate, may occur in the aged, though rarely in man compared 
with their frequency in cattle; they are white and dissolve with effer- 
vescence in mineral acids, (ii) Cystin calculi (Wollaston) are smooth, 
yellow, and waxy; they never exceed the size of a pea, are soluble in 
acids and alkalies and deposit hexagonal crystals when dissolved in 
acetic acid and ammonia. Only 60 cases are reported (Riegler, 1904). 
(hi) Xanthin stones (Marcet) occur almost exclusively in children; 
only 10 cases are recorded; they are smooth, yellow or brown, dis- 
solve in nitric acid, and on evaporation leave a residue which turns 
red on adding caustic potash, (iv) Only 3 cases of indigo stones are 
on record, (v) The fatty stones (urostealiths) described by Heller 
probably do not originate in the kidneys, but result from fatty sub- 
stances deposited in the bladder; they are 85 per cent, fat, and are 
soft, rubber-like, and combustible. 

Infarcts may be considered here, (a) Uric acid infarcts occur in 
gouty subjects and in 50 per cent, of the new-born, chiefly in the 
medullary collecting tubules, but sometimes in the cortex; they are 
most common in the still-born or in weakly infants, and are thought 
to result from destruction of the tissues or cells (nuclein). (b) Lime 
infarcts are chiefly phosphates and carbonates but sometimes oxalates ; 
they are deposited principally in the pyramids and in the membrana 
propria when the renal cells are destroyed; they occur in the aged, 
and also in poisoning by mercury, arsenic, phosphorus, or bismuth. 
(c) Pigmentary infarcts of hsematoidin, bilirubin, hsemoglobin or 
methsemoglobin are uncommon. 



RENAL CALCULUS (NEPHROLITHIASIS) 819 

Symptoms. — Stones may be first discovered accidentally at autopsy, 
or may pass without symptoms, though very exceptionally. Gravel 
or renal sand is more often latent than is stone. 

1. Pain is the most common symptom. It is of two kinds: (a) The 
dull pain in the loin, often associated with local tenderness over the 
kidney; Fen wick describes localized pain without any urinary changes, 
indicating that the stone lies in the medullary substance. Pain may 
be felt over the opposite kidney. (b) The renal colic, which arises 
from incarceration of the stone as it attempts to leave the pelvis, 
where it nearly always originates; it is often preceded by pain in the 
loin and may be initiated by exercise, as riding, or by indigestion or 
alcoholic indulgence. Eichhorst mentions a surgeon who had renal 
colic every time he drank white wine. The pain in renal colic begins 
over the kidney and radiates down the ureter to the testis, labia, bladder 
or urethra; the testicle is retracted. It may rarely radiate to the 
chest, heart, shoulder, epigastrium or to the opposite side. During 
the colic, the kidney is so frequently sensitive, that when it is not so, 
Israel hesitates to diagnosticate stone. The pain is cutting and is 
often very severe; it often occasions reflex nausea and vomiting, some- 
times chills, sweats and fever, or in children convulsions, and rarely 
collapse, or even death in most exceptional cases. Vesical tenesmus 
is frequent. If the stone passes, the pain is greatest as it enters the 
bladder. Constipation of a spastic order is much more frequent than 
diarrhoea or involuntary movements. Some observers hold that renal 
colic occurs oftenest at night. It lasts, with intermissions, a few hours, 
rarely days; movement may excite recurrence. The patient lies on 
his back with the leg drawn up and the abdominal wall rigid. After 
the attacks there may be dull pain (v.s.), which may be caused by 
large, numerous, or sharp stones. Eichhorst records a case in which 
the sole symptom was the patient's attitude; he leaned far forward 
and depressed one shoulder to avoid the pain induced by the erect 
attitude. 

2. The urine is almost invariably altered, (a) Hematuria occurs 
independently of pain and colic, as well as after them. Absence of 
hematuria after a renal colic, speaks strongly against a diagnosis of 
stone (Israel). It is often macroscopic, and red disks are always found 
with the microscope (Musser), except in the rare cases when stone is 
imbedded in the renal tissue, or there is permanent occlusion of the 
ureter. At the time of the colic the scanty, bloody urine is frequently 
voided with considerable tenesmus. In exceptional cases, early pro- 
fuse hematuria may result from vascular erosion. Musser found 
hyaline casts in nearly every case. (b) Anuria (suppression of urine) 
is not common. It may occur (i) with stone in one ureter, and disease 
or atrophy of the other kidney, (ii) with bilateral calculi (Albarran), 
(iii) with stone in one ureter, and reflex suppression (Morgagni) 
of the other (sound) kidney through the splanchnic nerve, or (iv) by 
urethral stoppage by a stone. Legeau (1891), quoted by Dieulafoy, 
collected 30 autopsied cases of calculous anuria; there was stone in 



820 DISEASES OF THE KIDNEY 

one kidney, and the opposite kidney (a) contained a calculus in 14 
cases, (/?) was hypoplastic in 3, (y) sclerotic in 6, (8) its ureter was 
stenosed in 6, and (e) in one case the opposite kidney was absolutely 
normal. The resulting symptoms resemble those of uraemia. How- 
ever, in 41 cases collected by Herter, convulsions were present in but 
12 per cent., headache in 14 per cent., and vomiting in 29 per cent. 
Consciousness is usually preserved, the pupils are usually narrowed 
and the temperature is low. Roberts speaks of this condition as 
"latent uraemia"; 11 cases of anuria persisted over four days, 18 
cases seven to fourteen days, and seven over fourteen days. Russel 
records recovery after twenty-eight days of anuria. With its relief 
large quantities of urine are voided, (c) Pyuria results in protracted 
cases from pyelitis, which is much oftener secondary to the calculus 
than primary. Rather infrequently a renal intermittent fever is ob- 
served, resembling the hepatic intermittent fever of gall-stones. Pyeli- 
tis may be catarrhal, suppurative, ulcerative or perforative, (d) 
Crystals of uric acid, and oxalates are considered especially important 
in the diagnosis by some writers, as Leube; Ulzmann regarded the 
pointed uric crystals as particularly suggestive of renal calculus; (e) 
Stones in the urine determine the diagnosis, though they are not 
frequently found. 

3. The x-rays may disclose renal calculi. It is certain that oxalate 
stones throw a darker shadow than uric acid stones. Opinions differ 
regarding the value of the arrays. The difference may be wholly 
technical, as Leonard reports the unusual figures of but 3 per cent, 
of errors; he found calculi in the ureter twice as often as in the renal 
pelvis. Kummel insists that every stone casts a shadow. 

4. The physical findings are generally less important than the 
urinary findings and the colic. Local tenderness has been mentioned 
(v.s., Pain). Enlargement of the kidney (hydro- or pyonephrosis) 
is not common. Palpation of the stone in the ureter is rarely possible, 
either from without or by the rectum or vagina, though once the 
writer felt a calculus at McBurney's point. Stones have rarely been 
felt to crepitate in the renal pelvis (Piorry). Cystoscopic examination 
and catheterization of the ureters are methods which can be employed 
only by the most expert, and have their disadvantages as well as 
advantages. M. L. Harris' segregator may determine which kidney 
is affected. 

Complications. — Ulcerative pyelitis may lead to perforation and para- 
nephric abscess. Pyelonephritis may develop. Hydronephrosis results 
from mechanical occlusion of the ureter, and pyonephrosis from obstruc- 
tion with infection. Injury to one kidney may be compensated by 
hypertrophy of its fellow. Amyloid degeneration, renal tuberculosis, 
or even cancer, from irritation, may develop. The ureter may rupture 
from ulceration or tension. Pregnant women may abort, and Troja 
instances a case in which 14 abortions occurred after 14 attacks of colic. 

Diagnosis. — The diagnosis is based on (a) the association of tha 
pain and colic, (6) hematuria, (c) pyelitic pyuria, (d) x-ray findings, 



RENAL CALCULUS (NEPHROLITHIASIS) 821 

and (e) less often, the anuria and acute swelling of the kidney. The 
results of the x-rays, if positive, are definitive; if negative, stone is 
not excluded. It is said that a diagnosis of stone is found correct in 
only 60 per cent, of the cases operated on. 

1. Pain and colic may occur, though rarely, in other renal conditions, 
as in renal embolism or passage of blood clots, parasites, echinococcus 
vesicles, malignant tissue or tuberculous detritus, renal aneurysm, 
capsular thickening and floating kidney. In one case previously 
operated on for appendicitis, the author made a diagnosis of calculus 
from pain, colic, and hsematuria; the operation by Murphy revealed 
a partial hydronephrosis from high insertion of the ureter. Confusion 
may result from vertebral disease, the crises of tabes or angioneurotic 
oedema, intestinal colic, gall-stones, appendicitis, diaphragmatic pleu- 
risy or hysteria. 

2. Hematuria (q.v.), associated with pain, may cause an error in 
diagnosis, which is usually corrected only at operation; thus acute 
congestion and particularly capsular fibrosis may be found. Israel 
states that there is a unilateral nephritis (a) with colic, (b) with albumin 
and without casts ; (c) with casts and without albumin ; (d) with hemor- 
rhage, simulating tumor; but (e) the bleeding never causes the colic. 
In these doubtful cases exploratory incision is also indicated. The 
hematuria resulting from cancer and tuberculosis does not improve 
with rest in bed, while calculous hsematuria usually does. Hsematuria 
and renal colic may develop in chronic nephritis from acute renal con- 
gestion (Israel). 

Prognosis. — The prognosis must be conservatively made, for the 
course is usually chronic and marked by relapses. The author knows 
of four physicians who passed calculi without symptoms afterward, 
but this is not the rule. Rupture of the ureter, collapse during the 
colic, pyelitis becoming pyelonephritis, anuria and uraemia must be 
considered in making the prognosis. Pyuria is a more ominous 
development than hsematuria. 

Treatment. — 1. Prophylaxis of renal calculus must be indefinite, 
because so little is known regarding its pathogenesis. It is usually 
stated that regulation of the diet concerns moderation in both proteids 
and carbohydrates; as in nephritis (q.v.) foods rich in nuclein are to 
be avoided; vegetables may be allowed. Acid foods and alcohol 
should be interdicted, water is given freely, and exercise must be 
insisted upon. In uric acid calculi, the alkaline waters are valuable, 
as those of Karlsbad, Vichy, Marienbad, Saratoga, Bedford, Poland 
and Mountain Valley. Sodium phosphate gr. x or bicarbonate 5 SS 
t.i.d. are indicated. It is questionable whether lithium carbonate is 
a uric-acid solvent; it is given in doses of grs. iij to v t.i.d. in effervescing 
waters. Piperazin and glycerin possess no proven solvent powers. 
In localities where calculi develop very frequently, the drinking water 
must be used with caution. Of course stones once formed cannot be 
dissolved by drugs. 



822 DISEASES OF THE KIDNEY 

If the oxalates are deposited, treatment is the same as in oxaluria 
(q.v.). In alkaline urines (from which phosphates are precipitated) 
the urine must be made acid by salol, gr. x t.i.d. ; acid waters, as 
Seltzer or Apollinaris may be employed; meats should be restricted; 
urotropin gr. x t.i.d. is excellent, especially in bacteriuria. Altogether, 
diatetic treatment, though important, has in the author's opinion, no 
great bearing on prophylaxis or treatment, and he cannot agree with 
those who declare that these measures are generally efficacious. 

2. The colic should be medically treated like that of gall-stones 

(q-v.). 

3. Surgical intervention is indicated by (a) anuria; (6) severe pyel- 
itis; (c) septic or aseptic obstruction of the ureter; (d) exhausting 
hematuria, and (e) repeated attacks of colic. As one or more of these 
conditions is present in most cases, successful treatment must be 
surgical. 

The ideal operation, advocated by Morris (1880) is nephrolithotomy 
(nephrotomy), closing the renal wound if there is no infection; opera- 
tion on the aseptic kidney entails a mortality of 3 per cent, and opera- 
tion in the presence of infection 10 per cent. (Albarran); in these 
cases the pelvis should be drained (nephrostomy). Tenny (1904) 
collected 134 cases of ureteral calculus; 122 were operated on, with 
a mortality of 19 per cent., or of 47 per cent, if pyelitis was present; 
anuria is a serious complication, for 52 per cent, of the operated cases 
die; without pyelitis or anuria, the fatalities were 6 per cent. Rosving 
has operated without a death. Medical treatment of anuria, with 
full doses of nitroglycerine, hot packs, cups to the lumbar region and 
subcutaneous saline transfusions should not last more than a day or 
two, for delay raises the mortality from operation; nephrostomy is 
indicated. 

(K). TUMORS OF THE KIDNEYS. 
I. Cancer. 

Etiology. — The etiology is obscure. It constitutes but 2 per cent, 
of all cancers and but 1 per cent, of primary cancers in adults (Rubin- 
stein); 62 per cent, occurs in males, and 32 per cent, in the first ten 
years of life. Its frequency in children was noted by Bright (though 
some reported cases were sarcomata), and it constitutes 52 per cent, 
of renal tumors in children (Hirschsprung). Weigert observed one 
case in a new-born child. Cancer in the pelvis may result from stone. 
In the Albarran and Imbert series of 380 renal tumors, cancer con- 
stituted 50 per cent. 

Pathology. — The primary form is usually infiltrating, and the 
secondary form consists of nodules. Medullary cancer is more com- 
mon than scirrhus, colloid, and other forms. It usually begins in the 
convoluted tubules of the cortex. Its growth is usually limited by the 
kidney's capsule. The kidney is nearly always enlarged, its average 



CANCER 823 

weight in children being 8J pounds (Guillet) and in adults 10 to 15 
pounds (or even 30 to 50) . The opposite kidney and the sound parts 
of the affected viscus may show compensatory hypertrophy. Hemor- 
rhages into the neoplastic tissue may occur. Local invasion of the 
renal veins, ureter, inferior cava, pancreas, adrenals or intestine and 
metastases (58 per cent.) in distant organs sometimes develop. 

Symptoms. — Some cancers are clinically latent, particularly secon- 
dary growths. 

1. Renal tumor is the most common finding, and occurs in 97 per 
cent, of cases (Guillet). It begins in the region of the kidney, but, 
being resisted by the firm lumbar tissues, it grows forward. Bimanual 
palpation clearly demonstrates its origin in most cases. If large, it 
may fall forward over the spine. It is tender and usually firm, though 
its degeneration may occasion slight fluctuation. The form of the 
kidney is usually preserved, though nodules may be palpated. It 
usually attains a large size (v.s.), compressing and dislocating the 
liver and spleen upward, and crowding the abdominal viscera. Fur- 
bringer reports a case in which the heart was pushed up to the clavicle. 
On tapping it a repercussion wave is sometimes noted (ballottement 
renal). Percussion gives a dull note, except so far as the intestines 
lie over it, when mixed flatness and tympany are elicited. The colon 
overlies the kidney, running from left to right, from above downward; 
on the left side this relation is more clearly distinguished; on inflation 
of the colon with air or gas, its tympanitic note in some degree obliter- 
ates the renal dulness; in a recent study by Kofmann, this condition 
was found in less than 50 per cent, of large renal tumors; in tumors 
on the right side the colon is often dislocated laterally or even down- 
ward. There is but little if any respiratory excursion. In rare in- 
stances the tumor may pulsate and produce by pressure on the aorta 
a systolic murmur, which, as in Richard Bright's case, may simulate 
aneurysm. If the tumor grows into the ureter, hydronephrosis may 
augment the swelling. 

2. Pain is an early and frequent symptom, due to pressure exerted 
on the lumbar plexus. For this reason also there may be slight sensory 
disturbance in the legs. Pain is usually dull and only rarely is it lan- 
cinating or colic-like, due to passage of clots or bits of tumor (v. L). 

3. Hematuria is an early symptom. According to Guillet it occurs 
in 50 per cent, and is the first symptom in 25 per cent, of cases; Israel 
holds that it occurs in 92 per cent, and is the first manifestation in 70 
per cent. It is less frequent in children (16 per cent.) than in adults. 
Sometimes worm-like blood clots are passed, with great colic; they 
sometimes measure one-half to one inch; clots in a clear urine are 
almost pathognomonic (Israel). The cystoscope and ureteral cathe- 
terization prove that the hematuria is unilateral. The hemorrhage 
usually originates in the diseased kidney but may come from the sound 
(though hyperaemic) kidney. In other repects the urine is generally 
normal. It is usually held that albuminuria corresponds to the amount 
of blood, but Albarran asserts there is more albumin than the blood 



824 DISEASES OF THE KIDNEY 

accounts for. Very rarely bits of cancer tissue pass. The urea is in- 
creased as in all cancers, and the chlorides are sometimes decreased. 
Pyuria is no part of renal cancer. 

4. Cachexia develops in most cases, but not in all. 

Complications. — Compression symptoms include paraplegia dolor- 
osa, constipation, intestinal obstruction, oedema from compression of 
the iliac veins and ascites; varicocele, which was first noted by Guyon, 
is said to seldom occur in other renal tumors, and is due to late com- 
pression of the spermatic vein by the tumor or contiguous lymph 
nodes. Metastases, enlarged inguinal glands, rarely growth into the 
lumbar muscles or skin, and perforation into the peritoneum or intes- 
tine, with fatal hemorrhage, ursemia, fever from cachexia or terminal 
infection, may be observed. According to Israel, tumor of the renal 
pelvis causes greater hematuria, and more hydronephrosis (therefore 
greater variations in the size of the tumor) ; it sometimes grows down 
the ureter and is seen with the cystoscope to project into the bladder; 
particles of tumor tissue and cells are more often obtained. Albarran 
and Imbert collected 65 cases of tumors in the pelvis and ureter; 27 
were ureteral. Savory and Nash collected 60 cases of painful villous 
tumors in the pelvis. 

Course and Prognosis. — Death is invariable without operation; it 
usually results from cachexia, in two years in adults and in eight 
months in children (Rohrer and Roberts). Guillet states that 6 cases 
have lived longer than ten years and 1 lived seventeen years, 

Diagnosis. — The following are of clinical importance: (a) renal 
tumor, (6) pain, (c) hematuria, and (d) cachexia. Imbert speaks of 
the complete type (tumor and hematuria), the hsematuric type (without 
tumor, 6 per cent.) and the tumor type (without hematuria, 23 per 
cent.). 

Differentiation is necessary, from (a) liver tumor, which encroaches 
much more upon the diaphragm and is characterized by its respiratory 
excursion, by the location of the tumor within the edge of the liver, 
and by such complications as icterus and ascites. The colon lies 
below the liver and there are no urinary findings. Bimanual palpation 
clearly differentiates uncomplicated cases. Between a kidney tumor 
and the liver a furrow and loop of resonant intestine are frequently 
found, (b) A splenic tumor maintains the form of the spleen, lies above 
the colon, (whose distention does not modify the splenic dulness), 
moves on inspiration, shows the characteristic notches and seldom 
causes confusion except when it so rotates that only its convexity can 
be felt, (c) An ovarian tumor projects upward from the pelvis, with 
which its connection can be demonstrated, save when it has a long 
pedicle. It is more central and sustains no characteristic relation 
with the colon, (d) Retroperitoneal growths are much more difficult 
to differentiate, especially enlarged lymph glands and lymphosarcoma. 
They are generally more central and less movable. The author 
recalls an enormous tumor which was considered renal, but which 
proved at autopsy to be a retroperitoneal lipoma, (e) Other renal 



HYPERNEPHROMA 825 

conditions must be differentiated, (i) Cystic degeneration (v.i.) is 
usually bilateral and runs a most chronic course, (ii) Sarcoma cannot 
be differentiated, (iii) Hydro- or pyonephrosis (q.v.), in which the 
tumor varies exceedingly and has characteristic urinary changes, (iv) 
Tuberculosis is distinguished by hectic fever, tuberculosis elsewhere, 
pyuria, and finding of the tubercle bacilli. 



II. Sarcoma. 

Sixty-six per cent, occurs under ten years of age; G. Walker in 
145 cases, found that most cases occurred in the first two years of life. 
Albarran and Imbert state that sarcoma constitutes 20 per cent, of 
renal growths. It is slightly more common in girls than in boys, and 
in the left than in the right kidney. Cohnheim's theory of embryonal 
inclusion is supported by the occasional presence of cartilage, bone, 
and striated and unstriated muscle. The sarcoma is of the round, 
spindle or melanoid cell type and may contain furrows, fatty, vascular, 
and even carcinomatous tissue. It may weigh 6,000 gm. Secondary 
sarcomata may develop by metastasis from other organs, or by invasion 
by contiguity. 

Its symptoms are essentially those of carcinoma, from which an 
intravitam diagnosis is very rarely possible, except when sarcomatous 
tissue is passed in the urine or excised at operation. Hematuria and 
cachexia are infrequent; age is of no diagnostic value, and glandular 
involvement may occur in either. In some cases a remarkable over- 
growth of the pubic and axillary hair, and pigmentation of the skin 
may be observed. Operated cases live on an average sixteen months 
and non-operated ones, half as long (G. Walker) but death is frequently 
a direct result of the operation. 

III. Hypernephroma. 

P. Grawitz named this form "struma lipomatodes aberrans renis"; 
the tumor develops from aberrant (included) particles of adrenal 
tissue. Small tumors are not a rare autopsy finding. They constitute 
20 per cent, of renal tumors and consist of a scanty but vascular 
connective tissue stroma, containing fatty cells like those of the adrenal 
bodies. Hemorrhage, cystic degeneration, a tendency to invade the 
veins, and a large proportion of glycogen and perhaps cholestearin or 
lecithin are considered characteristic. Fatty cells may be found in 
the urine. Hsematuria occurs in 80 per cent, of cases. Metastases 
may develop. Bone metastasis is the first symptom in 16 per cent, 
but may develop as a late symptom only. Fever is noted in 57 per 
cent., though it occurs in but 1 or 2 per cent, of other tumors of the 
kidney (Israel). 



826 DISEASES OF THE KIDNEY 



IV. Other Tumors. 

Other tumors as fibroma, lipoma, myxoma, angioma, and rhabdo- 
myoma are of little importance. Hematuria occurred in only one 
case, an angioma. Thirty-three cases of tumor of the capsule are 
on record. 

Treatment of Renal Tumors.— This is symptomatic and surgical. 
The former concerns chiefly the management of pain, by means of 
anodynes, chiefly opiates. Surgical treatment alone is of value. The 
mortality resulting from total nephrectomy in Gross' figures was 61 
per cent.; in Kuster's, 24 per cent. Schmieden collected 329 cases; 
33 per cent, (average) have died from the operation; the mortality 
in the first decade of renal surgery (dating from Gustav Simon, 1869) 
was 64 per cent., in the next 43 per cent., in the third 22 per cent. 
The mortality of nephrectomy for all causes is at present 17 per cent, 
and for tumor 22 per cent, (in children, 28 per cent.). Thirty-three 
recoveries after radical operation are on record, one patient being 
alive after eighteen years. Israel in 43 cases reported a mortality 
of 18.6 per cent., of which two-thirds died of heart paralysis; 8 cases 
(19 per cent.) enjoyed permanent recovery, after three and a half to 
fourteen years. Schede in 18 operations obtained 4 permanent recov- 
eries (22 per cent.) after four to nine years. Recurrence after two 
years is very exceptional. The extraperitoneal operation is three 
times as safe as the transperitoneal. Operations are usually performed 
too late; advanced cachexia, very large tumors, metastases and growth 
into the cava are contra-indications. The other kidney must be in 
good condition to admit of operation. 



(L). CYSTIC DEGENERATION. 

Various renal cysts are observed, (a) Those which occur in chronic 
interstitial nephritis are the most frequent; they result from snaring 
off, by fibrous tissue, of the tubules and glomeruli, (b) Parasitic 
cysts (v.i.) are next in frequency, (c) Dermoid cysts are very rare; 
but two are on record, (d) Cysts of the fatty capsule, retroperitoneal 
cysts, and degenerated lymph glands, are also very rare, (e) Complete 
cystic degeneration (hydrops renum cysticus, degeneratio renum poly- 
cystica) was first separated by Rayer from the above mentioned var- 
ieties and constitutes cystic degeneration, as it is generally understood. 

Etiology. — Over 50 per cent, is observed in men between forty 
and fifty years of age. Luzzatto found but two cases (in 187) in per- 
sons under twenty years; Sieber (1906) collected from the literature 
32 cases of cystic kidneys in persons under and 211 in those over 
twenty years of age. Cystic kidneys are observed in later foetal life, 
at birth, and in the adult. It is often difficult to determine whether 



CYSTIC DEGENERATION 827 

they are acquired or congenital, though the latter conception is most 
favored; the cysts are thought to remain latent until middle life. 

Pathogenesis. — Three main theories obtain; (a) that they are 
retention cysts, (b) that they are new formations, i.e., neoplastic 
(cystadenomata), and (c) that they are malformations. The neoplastic 
conception is probably the most acceptable hypothesis. 

Pathology. — Congenital cases are almost always bilateral; Lejars 
found one unilateral case in 67, and Luzzatto 41 in 226 cases. The 
kidneys may contain innumerable small cysts, when the shape of the 
kidney is preserved, or it contains larger cysts, when its contour is 
more irregular. According to Englander, only 23 cases of unilocular 
cysts are on record. The size of the kidneys may be that of a child's 
head; they may even weigh twenty-one pounds. In congenital cases 
it sometimes causes dystocia. On section the kidney is honey-combed. 
The cyst walls consist of thin or thick fibrous tissue. The cysts usually 
contain thin, yellow, transparent fluid, less often milky, gelatinous or 
brownish contents (altered blood). They are uni- or multilocular. 
They are lined with cells like the urinary tubules, or with flat polyg- 
onal cells. The cysts contain albumin, oxalate of lime, leucin-like 
crystals, red disks, epithelial detritus, fat granules, and rarely urea or 
uric acid. Between the cysts vestiges of renal tubules or glomeruli are 
found, which here and there may be vicariously hypertrophied. 
Cysts may occur in the pelvis, ureter and liver (v.i.). In congenital 
cases other deformities are sometimes found, particularly in the genito- 
urinary tract, brain and fingers. 

Symptoms. — In congenital forms the cystic kidneys may cause an 
obstruction to delivery; if the infant is born alive, death from asphyxia 
is usual, for the diaphragm is crowded upward. In adult forms, 90 
per cent, of cases come to autopsy, undiagnosticated, or with the 
diagnosis of some other renal disease as nephritis. The symptoms 
may be classified as follows: (a) Renal cysts are found clinically in 
29 per cent, of cases only (Luzzatto) or in 12.4 per cent. (Sieber). 
Their general characteristics are those of solid kidney tumors, but they 
are almost always bilateral (v.s.). Fluctuation seldom occurs. In 
very few cases the individual cysts can be palpated; in a case which 
the author demonstrated in the Chicago Medical Society they could 
be clearly palpated. Echinococcus cysts, hydro- and pyonephrosis, 
sarcoma and cancer of the kidney are only distinguished by their 
unilateral occurrence; if bilateral, differentiation is almost impossible. 
(b) The urine is variable; it may be normal, increased or decreased. 
The urinary findings are typically like those of interstitial nephritis, 
i.e., the urine is abundant, with few solids, low specific gravity, and 
traces of albumin. Red disks are often found (20 per cent.), some- 
times in great numbers. In two of the author's cases red cells appeared 
in numbers each time the kidneys were palpated. Leucin-like bodies 
may appear in the urine, or in exploratory punctures; Beckmann first 
described these small colloid bodies ("rosettes") with structureless 
centres and one to five concentric rings and clearly radiating striations. 



828 DISEASES OF THE KIDNEY 

(c) Cardiovascular changes (left ventricular hypertrophy and sclerosed 
arteries) are common and heighten the resemblance to contracted 
kidney. The changes were well marked in the three cases which the 
author was able to diagnosticate, (d) Uramia is the common cause 
of death. The clinical course is very chronic and is broken by attacks 
of " periodic uraemia." The digestive disorders of uraemia (see Chronic 
Interstitial Nephritis) are very frequent. Lejars observed a case 
living fifteen years, and Senator one living twenty years after the 
cysts were found. 

Diagnosis. — The diagnosis is difficult in many cases, but can be 
made when there are (a) bilateral (perhaps palpably cystic) renal 
swellings; (b) the cardiovascular and urinary findings of contracted 
kidney, with hematuria and colloid "rosettes," which are obtained 
in the urine, or by puncture; (c) uraemia and (d) perhaps renal pain, 
and tenderness or congenital cysts in the liver (in 28 per cent., accord- 
ing to Lejars); in a case of Dr. W. F. Dickson of Chicago, renal 
cysts were found with cystic liver, atrophic heart, and pain resembling 
appendicitis (see Echinococcus of the Liver, Differentiation). 
Hanot and others describe cases resembling calculous colic. 

Treatment. — Operation is permissible only in the exceptional, uni- 
lateral cases, or when suppuration develops. About one-third of the 
operated cases die immediately, and in few are any lasting results 
obtained. The treatment is that of chronic nephritis. 

(M). RENAL PARASITES. 

Echinococcus cysts (see section on Animal Parasites) of the kid- 
neys, occur in 9 per cent of echinococcus disease (Neisser's 900 cases). 
In 970 cases (Vegas and Cranwell), the liver was diseased in 64 per 
cent., the lungs in 7 per cent., the spleen in 3 per cent., and the kidneys 
in 2 per cent. Baradulin in 1906, collected 142 cases of renal echino- 
coccus. 

Symptoms. — (a) A renal tumor is found in 50 per cent., when the 
cyst attains large dimensions. It is easily confused with other cysts, 
hydronephrosis, cancer, or tuberculosis without the exploratory punc- 
ture, and the urinary findings. Fluctuation and the hydatid thrill 
(see Liver Echinococcus) are not often found. The cyst begins in 
the cortex, and usually in either pole of the kidney; it is unilateral 
in|96 per cent, of cases, and is left-sided in 62 per cent. If the cyst 
calcifies it may be seen by the rr-rays. The opposite kidney may 
hypertrophy, (b) Exploratory aspiration may show (i) fluid or pus, 
containing urinary constituents, cholestearin, succinic acid, much 
sodium chloride and a reducing substance; (ii) vesicles, hooklets, or 
particles of lamellated membrane, (c) The urine may contain ves- 
icles, hooklets, membrane, pus from pyelitis, and blood from rupture. 
As many as 100 vesicles have been passed, (d) Passage of vesicles 



RENAL PARASITES 829 

is attended by colic, as severe as that of nephrolithiasis, with fever, 
chill, and vomiting. 

Complications. — Seventy-five per cent, rupture, chiefly into the renal 
pelvis; perforation may occur into the intestines, lumbar muscles, 
lung or pleura ; the patient may feel the rupture. The toxic substances, 
liberated by rupture or puncture, may cause urticaria, severe heart 
symptoms or even fatal syncope. Adhesions to the liver, spleen, and 
intestine may form. Suppuration or gangrene may develop (pyone- 
phrosis or paranephritis). Obstruction of the ureter causes hydro- 
nephrosis; vesicles which plugged the lower end of the ureter have 
been seen with the cystoscope. 

Prognosis and Treatment. — The course is very chronic, covering 
years (even twenty to thirty). Suppuration may cause pyaemia. The 
cyst may shrink or calcify. Bilateral involvement makes the prognosis 
unfavorable. Spontaneous recovery by rupture into the urinary tract, 
occurs in 32 per cent. (Beraud). Operation should be extraperitoneal. 
Nephrotomy is indicated, as there is seldom more than a single cyst. 
Nephrectomy produces a higher mortality (8 per cent.). In 30 opera- 
tions (nephrotomy), by Schede, there were no fatalities; 87 per cent, 
completely recovered, and 10 per cent, recovered but had fistulse. 

The Enstrongylus gigas, which occurs frequently in dogs or wolves, 
is very rare in man. It is a nematode whose ova appear in the urine. 
It causes pyelitis, hematuria, colic, tenesmus and sometimes chyluria. 

The Distoma haematobium, described by Bilharz (1851) in Egypt, 
causes endemic hematuria. It is a trematode and enters the alimen- 
tary tract, by the drinking water. Reaching the veins, its ova obstruct 
them and cause pyelitis, haematuria, tenesmus, and sometimes form 
the nucleus of renal stones. Salol is said to be beneficial. 

The filaria has been mentioned under Chyluria. 

Tuberculosis and syphilis of the kidney are considered under 
Infections. 



SECTION VI 



DISEASES OF THE BLOOD. 



Anaemia is a reduction in the blood as a whole, or more often a 
reduction of its important constituents, as the red corpuscles, their 
number, haemoglobin or albumin. Every anaemia has a cause, yet in 
our present ignorance, we adhere to the older division of anaemia 
into primary and secondary forms. Primary ancemia includes chlorosis 
and pernicious (progressive) anaemia. 



(A). CHLOROSIS. 

Definition. — Chlorosis is a disease of haemogenesis, occurring almost 
invariably in women, chiefly in the developmental years and in the 
decennium following, in which the cardinal symptom is anaemia; 
the red cells are reduced but the haemoglobin is disproportionately 
reduced; chlorosis develops spontaneously, usually runs an uncom- 
plicated course, tends to recur, and responds to therapy by iron. 
Chlorosis is a disease, while anaemia is but a symptom. 

Etiology. — Its etiology is uncertain, (a) Nearly all cases occur in 
women; a few alleged instances in delicate men are recorded. It 
develops especially in girls who menstruate before the pubes and 
mammae develop (Niemeyer). It is more common in blondes than 
in brunettes, (b) Chlorosis occurs largely between the fourteenth and 
seventeenth years. Great care must be exercised in diagnosticating 
the disease, after the twenty-fourth year (chlorosis tarda), unless 
previous attacks have occurred, (c) Heredity is undoubtedly a marked 
factor (Bramwell). Chlorosis, tuberculosis or hysteria is not infre- 
quently associated in the family history, (d) Malnutrition, lack of 

831 



832 DISEASES OF THE BLOOD 

hygiene, insufficient or excessive exercise, working in dark quarters, 
nostalgia, improper clothing, wearing of corsets, and emotional or 
sexual factors (unsatisfied desire, masturbation), are indirect causes. 
Various theories have been advanced as to the nature of the disease, 
as deficient development of the genitalia, hypoplasia of the vascular 
apparatus, adynamia of the blood-making organs, reflex action of the 
nutritive organs from genital maturity, inability of the blood-making 
organs to respond to the bodily needs at puberty, insufficient absorp- 
tion of iron, dilatation of the stomach, constipation, enteroptosis, 
auto-intoxication from the internal genitalia at the time of puberty, 
and intestinal auto-intoxication. 

General Symptoms. — Among the early symptoms are rapid tiring, 
dyspnoea and palpitation, which are rarely absent and are most notice- 
able in the morning. Pallor is the earliest and most constant sign and 
affects the skin and mucosae, the skin being of a yellowish-green hue 
(chlorosis, as named by Varandel, in 1670). Sometimes the color is 
maintained, the face being flushed, probably from peripheral irrita- 
bility of the vasomotor system (chlorosis rubra); hence the mucous 
membranes should be examined, even more than the skin. The 
eyes are often brilliant. Psychical changes are noted (Sydenham and 
Morton), as stupor, and lack of mental and muscular energy. Associated 
symptoms are headache, which may be dull or sharp, sometimes mi- 
graine-like, or increased at the time of menstruation, spots before the 
eyes, tinnitus, vertigo, and syncope which occurs especially on stand- 
ing and results from travel and exposure to the sun, but less from 
movement. Menstrual disturbances are frequent, the flow being often 
decreased, most markedly in younger subjects. Digestion is very 
frequently disturbed, and there may be anorexia, perversity of appetite, 
craving of sour articles, hunger between meals, pain in the stomach, 
eructations and cardialgia. Constipation is frequent. The hands are 
cold, the skin dry and the peripheral circulation sluggish. Circulatory 
symptoms appear, as the bruit de diable in the neck veins, anemic 
heart murmurs and rapid pulse. 

Special Symptoms. — 1. The blood is fluid and its coagulability is 
increased, thereby contrasting with pernicious anaemia and leukaemia. 
The red blood cells are decreased (oligocythemia) and average three 
to four millions at the first examination ; as few as one million red cells 
have been observed. In some rare cases they are not decreased (Dun- 
can, Hayem, Laache). Formation of rouleaux is poorly marked. 
The red cells appear pale and their average size is reduced. Irregularity 
in contour (poikilocytosis) is not frequent; megalocytosis and micro- 
cytosis are rare; normo- and megaloblasts are found only in the 
severest cases; normoblasts are sometimes present in "blood crises." 
More suggestive than the red cell reduction (oliogocythaemia) is the 
reduction of haemoglobin (oligochromamia) , which is reduced more 
than the red cells (Duncan, 1867) ; the haemoglobin averages 30 to 40 
per cent. This reduction in the color index always suggests chlorosis, 
is most marked in the first seizure in young individuals, and is less 



CHLOROSIS 833 

conspicuous in relapses or in older individuals. Some writers claim 
that the reduction in haemoglobin is more apparent than real, because 
there is more rapid regeneration of the cells than of the haemoglobin. 
The white cells are essentially normal, or at least but little increased, 
therein differing from many other forms of anaemia; occasionally 
lymphocytosis and eosinophilia occur. The iron and nitrogen of the 
blood and its specific gravity are reduced proportionately to the de- 
crease in haemoglobin. 

2. The vascular system presents various symptoms, (a) Rokitansky 
and Virchow observed hypoplasia of the aorta and vessels, which 
may co-exist with hypoplasia of the genitalia, muscles and bones, but 
cannot be regarded as causative, (b) Palpitation is almost constant 
on exertion; the apex-beat is strong to compensate for the poverty in 
haemoglobin, (c) Heart murmurs occur in two-thirds of the cases; 
they are largely functional and may be caused by insufficient tension 

•of the mitral valve, dilatation of the left ventricle causing relative 
mitral insufficiency, weakened heart muscle (producing a muscular 
murmur in place of the tone), tricuspid insufficiency or vibration of 
the pulmonary artery. The murmurs are largely systolic; undoubted 
diastolic venous bruits have been heard, (d) Dilatation of the heart 
occurs from anaemia or myocardial degeneration, though according 
to Leube, Grunmach and von Noorden, the dilatation is not real but 
apparent, being due to retraction of the lungs away from the heart, 
because of insufficient lung expansion; this has been confirmed by 
the #-rays. (e) The pulse findings are not constant; the pulse may 
be rapid, throbbing, or excitable. The arterial tonus is reduced, 
dicrotism and capillary pulsation are frequent, and double tones have 
been noted in the crural vessels from decreased tension and diastolic 
recoil. (/) A venous bruit (bruit de diable) in the neck occurs in over 
50 per cent, of cases, and more frequently than in other anaemias; 
it may be palpable and is heard more frequently over the right jugular 
vein, because it is more vertical than the left; it also is heard in other 
veins, and in sound individuals. It is increased in the sitting posture, 
by turning the head to one side, and by deep inspiration. Its explan- 
ation is difficult; it is referred to change in the tonus of the vessel, 
waves in the veins above their valves, and a change of the blood 
plasma, (g) Arterial murmurs may be heard, as over the subclavian 
artery; pulsation in the peripheral veins, angiospasm, and erythro- 
melalgia, have been observed, (h) (Edema is seen in 12 per cent, of 
cases, and is usually slight, occurring chiefly about the ankles and 
eyes, and rarely in the serous cavities. 

3. In the respiratory tract, dyspnoea is a common complaint, and is 
described by Eichhorst as an hematogenous respiratory insufficiency. 
The respiration rate is 26 to 30. Sometimes a paroxysmal cough 
develops. 

4. The digestive tract is involved in 31 per cent, of cases. There 
is sometimes factor ex ore. (a) Pain in the stomach is frequent; it 
may occur near the ensiform with tenderness, especially in nervous 

53 



834 DISEASES OF THE BLOOD 

individuals. It sometimes results in vomiting, and may be associated 
with pyloric cramp; similar pains occur in the transverse colon. 
Sensitiveness at the tip of the twelfth costal cartilage is due to pressure 
from corsets, (b) Dyspepsia may be purely nervous. The stomach 
is exceptionally dilated and atonic, but as a rule no motor insufficiency 
occurs. Corsets and chlorosis may cause gastroptosis. (c) The hydro- 
chloric acid, formerly thought to be decreased, is increased in 80 to 
95 per cent, of cases; nervous irritability is its most probable cause. 
(d) It is said that constipation is usually present, but it is probably 
no more frequent than in the average case; intestinal fermentation 
may co-exist but it is not the cause of chlorosis. 

5. In the sexual sphere there may be symptoms. The uterus infantilis 
and small ovaries are not causal, but are coordinate with chlorosis, 
being evidence of degeneration or hypoplasia. Menstruation is de- 
creased or absent in 80 per cent.; menstrual disturbance is neither 
the cause nor result of chlorosis; both result from a common factor.- 
Conception is unlikely to occur during a chlorotic attack. Chlorotics 
are often first treated by the gynaecologist, for leucorrhcea (in 22 per 
cent, of cases). 

6. Special senses. The usual symptoms of anaemia, as spots before 
the eyes, and weakness of accommodation, are observed. The retinal 
vessels may be transparent or pulsating; retinitis and neuroretinitis 
with degeneration and exudation, or " choked disk," occur in excep- 
tional cases and simulate brain tumor. Retinal hemorrhage is rare. 

7. The skin is usually anaemic; angiospasm, coldness, and par- 
esthesia occur. In chlorosis rubra the cheeks are flushed. Seborrhoea 
and acne are very common. Sweats, urticaria, eczema, purpura, 
chloasma and trophic disturbance of the hair and nails may occur. 

8. The nervous system may be affected. Chlorosis often brings out 
a latent neurosis, — especially hysteria, — and psychosis, the latter of 
which is frequently curable. Neuralgia is infrequent. 

9. Metabolism is not essentially disturbed. The body- weight is 
maintained, less from decreased oxygenation than from inactivity or 
water retention. Some cases are emaciated, and occasionally an actual 
gain in weight is noted. The urine is clear, of low specific gravity, 
often alkaline with decrease of urea and uric acid and sometimes 
albuminuria. Fever is usually held to indicate a severe anaemia, 
though Leube has found it frequently in mild chlorosis. When present 
it is always well to differentiate " tuberculous pseudochlorosis." 

Complications. — Chlorosis may induce acute infections, as typhoid, 
pneumonia, influenza and scarlatina, and may render their clinical 
course severe. Venous thrombosis complicates 2 per cent, of cases, 
occurring largely in the femoral veins, sometimes in the cerebral sin- 
uses, and axillary and other vessels. It is probably inflammatory. 
In Leichtenstern's series of 86 cases with thrombosis, 56 per cent, 
involved the veins of the leg and 34 per cent, the cerebral sinuses. 
Pulmonary embolism occurred in 25 per cent, of 52 cases of throm- 
bosis of the lower extremities (Welch). Virchow emphasized the 



CHLOROSIS 835 

frequency of septic endocarditis. Rheumatic endocarditis with organic 
valvular lesion is frequent, as also are ulcer of the stomach, tuber- 
culosis and Basedow's disease. The spleen is enlarged (in 37 per cent, 
according to Chvostek, or in 16 per cent., according to Leube). The 
thyroid gland is often moderately enlarged. Hemorrhages are not 
infrequent from the nose, stomach or intestine, although it is usually 
stated that they occur mostly in severe or pernicious anaemias. 

Clinical Course and Prognosis. — Simple chlorosis develops rather 
suddenly in a few days or weeks. It runs a relatively short course 
of two to three or four months. The prognosis is generally good. The 
tendency to recurrence is great, especially in unmarried or childless 
women ; the blood may not return absolutely to normal ; this is shown 
by persistent pallor or irregular menstruation. Acute chlorosis is 
observed especially in young girls after their first menstruation; it 
is attended by severe headache, nervous symptoms, great weakness 
and optic neuritis or "choked disk," and may be confused with organic 
disease, as brain tumor. The periodic type, according to Von Noorden, 
occurs in the higher classes and in those who acquire the disease in 
their seventeenth to nineteenth year. The course may be chronic; 
the disease may last for years with chlorotic blood, menstrual, dyspep- 
tic, muscular and nervous symptoms, with alternate exacerbation and 
amelioration, indicating an essential inactivity or hypoplasia of the 
blood-making organs; this form begins early in life in individuals 
with poor development of the bones, muscles, genitalia, mammae, and 
adipose tissue; marriage, pregnancy, and iron often benefit these cases 
but they may last until the menopause. 

Diagnosis. — It must be remembered that the diagnosis cannot be 
made by any single symptom but by the entire group of symptoms, 
both positive and negative, for no single symptom is pathognomonic. 
The diagnosis is based upon the ancemia, especially when there is 
disproportionate reduction in the haemoglobin, when the color index is 
less than one, and the white cells are normal; a diagnosis, however, 
cannot be made from the blood findings alone. (Rhomberg has de- 
scribed exceptional cases in which the blood was normal.) Chlorosis 
is infrequent before the twelfth and after the twenty-fifth year, unless 
the attack is a relapse. Its rapid development and periodic manifes- 
tation are important features. Successful treatment with iron is prac- 
tically diagnostic. Secondary anaemia is most difficult to differentiate 
(see Differentiation under Pernicious Anaemia) ; it is usually at- 
tended by some leukocytosis. Anaemia from intestinal parasites, 
hemorrhage from latent ulceration of the stomach or bowel, renal 
disease, early pregnancy in unmarried girls, the anaemia of heart 
disease, incipient brain disease, rheumatism, and lead and arsenic 
anaemias, must be considered. Splenic ancemia, especially in children, 
requires differentiation; cases of chlorosis with enlarged spleen are 
regarded as a transitional form between chlorosis and splenic anaemia 
proper. Malignant disease usually causes little diagnostic difficulty 
after careful examination. There is sometimes great difficulty in 



836 DISEASES OF THE BLOOD 

differentiation from incipient tuberculosis. Frequent physical exami- 
nation and watching of the temperature usually establish the diagnosis. 

Treatment. — Prophylaxis includes general hygiene and proper 
nourishment, in that development of adipose tissue to a reasonable 
extent is prophylactic. More albumin should be given to growing 
children than to adults, although fruit and vegetables, for their iron, 
and butter, cream and oils, rather than animal fats, should also be 
administered. Physical culture and trips to the country are valuable, 
and constipation should be prevented. Education should not be hur- 
ried; all children at this age are confined too much to the school-room; 
they should be kept children as long as possible. In society, and in 
the struggle for existence, young girls too often overtax their strength. 

Specific Therapy. — Iron exists in the haemoglobin of the blood cells, 
as an oxygen carrier, and is a food as well as a medicine; it is found 
in blood, meat, oatmeal, peas, spinach, beans, and the yolk of eggs. 
Milk is poor in iron. 

Physiological Action of Iron. — (a) The tonus of the nervous system 
is increased, though an excess produces frontal headache from con- 
stipation; some persons show a peculiar intolerance of iron, as shown 
by the headache, the vertigo and the palpitation which it produces. 
(b) It affects the circulation; locally astringent, it coagulates albumin 
and contracts the bloodvessels. It increases the number of red disks 
and the amount of haemoglobin, (c) Its action on the gastro-intestinal 
tract is as follows : iron stains the teeth because of the acid which it 
contains. Small doses stimulate digestion, improving, by their astrin- 
gent action, the tone of the tissues. Hydrogen is generated and from 
it sulphureted hydrogen, which causes eructations. Small doses cause 
constipation, but large doses relax the bowels; diarrhoea also some- 
times follows small doses. Sulphide of iron is found in the dark stools. 

(d) The amount of urine is increased. Iron is found in the urine in 
very small quantities. The kidneys may be irritated by very large doses. 

(e) In regard to its absorption, there is great conflict of opinion, and 
experiments are incomplete. There are four theories : (i) That iron 
is absorbed from the stomach and intestines as an albuminate; it 
reaches the blood and is deposited first in the spleen and then in the 
liver, whence it is then carried by the bloodvessels to the intestines 
for elimination. Although Schmiedeberg and Kobert insist that iron 
is not absorbed, there is strong clinical evidence that it is. (ii) That, 
being an astringent, it calls forth tonicity of intestinal tissues and 
stimulates absorption of other foods, which is probably also true, (iii) 
Bunge's theory is that in anaemia, hydrochloric acid is deficient and 
allows fermentation ; that iron acts by neutralizing the alkaline sulphides 
(products of fermentation) and allows iron in albuminous food to be 
absorbed, as it thus escapes union with sulphides. This theory is now 
abandoned, (iv) On reaching the blood, it acts as a stimulant to the 
blood-making centres. (/) Elimination occurs by the intestines, the 
kidneys and liver. 



CHLOROSIS 837 

Administration. — It may be advantageously combined with quinine, 
particularly when the spleen is enlarged; it may also be given with 
oxygen, normal salt transfusions, and massage; the patient should 
have rest and change of environment, and climate. Soluble prepara- 
tions would seem to be better than insoluble ones, but Quevenne has 
shown that they are precipitated by the gastric juice. Headache may 
occur; it is obviated by using laxatives, bromides or ferrous salts, 
which derange digestion less than ferric salts. Iron is said to be 
best absorbed when some gastric catarrh exists (Brunton), hence 
some practitioners give large doses at first, to improve absorption. 
There are only 38 to 45 grains of iron in the body and the ordinary 
daily diet contains but one-sixth of a grain of iron, but the nucleo- 
albumin preparations, which are sufficient as food, are not sufficient 
as medication, because they do not stimulate the blood-making 
centres. The rules for administration, according to von Noorden are: 

(a) The doses should not be too small (Niemeyer and Immermann). 

(b) Every physician has his own method, therefore no one form espe- 
cially excels any other, (c) The administration should be regular, 
for irregularity is injurious. Statements of the patient that she has 
previously taken iron should not be regarded, for its administration 
may have been irregular, (d) Administration should continue for six 
weeks to three months. In the first week the dose should be gradually 
increased; for three weeks the maximum dose should be given and 
for the last two weeks it should be gradually decreased, (e) If iron 
is not beneficial, it should not be repeated but other methods tried. 
(/) Relapses are less easy to treat than the first attack, (g) Idiosyn- 
crasy, as gastro-intestinal disturbance, is only a relative contra- 
indication. The administration should then be subcutaneous, (h) At 
mineral springs, hygiene is more important than iron ; the water should 
be taken on an empty stomach, for the gas promotes absorption of 
iron. When bottled it is precipitated as a carbonate. 

Iron may be given in the following forms: Ferrum reductum (reduced 
iron) which is iron gray (if it is black, it is impure), and tasteless; 
it is least astringent, but may cause eructation; gr. j. (See formula 
for reduced iron given under Therapy of Valvular Disease, page 
428). Pilula ferri carbonatis, a ferrous salt nearly free from astringency ; 
grs. ij to v. Ferri sulphas (green vitriol), a ferrous salt which is very 
astringent, whence its use in chronic diarrhoea. It stimulates digestion. 
In large quantities it is toxic, causing vomiting or diarrhoea. Smart 
considers it the best form: gr. ij should be given with one dram of 
magnesium sulphate p.c. Ferri sulphas exsiccatus gr. ss to ij (gm. 
0.03 to 0.12) may also be given. Liquor ferri et ammonii acetatis 
(Basham's mixture) is a vascular tonic and diuretic; it is excellent for 
chlorosis in the obese; 5j to iv should be given after meals, well 
diluted. Tinctura ferri chloridi is the chloride of iron plus hydrochloric 
acid and alcohol, which develop hydrochloric ether. It is yellow-red, 
astringent, somewhat corrosive and diuretic, increasing the amount and 
frequency of micturition. It is used to best advantage when the tongue 



838 DISEASES OF THE BLOOD 

is white, flabby, and indented. In weak, anaemic girls, with vomiting, 
neuralgia and epigastric pains, full doses should be given ; when poorly 
tolerated, one drop in a full glass of water should be given ; this is more 
beneficial than most chalybeate waters. Syrwpus jerri iodidi is trans- 
parent and has a greenish color ; iron and iodine given separately are 
usually more beneficial, but the syrup may be given in doses of 30 to 
40 drops in adults and of 5 to 10 in children. Ferri extras in doses of gr. 
v, is efficacious in children and in persons having delicate stomachs. 
Ferri phosphas solubilis, gr.v, is almost free from astringency and 
taste. The organic preparations are generally useless. Ovoferrin, 
however, is excellent. The author thoroughly agrees with the conclu- 
sions of R.W.Wilcox: (a) It is the exact chemical form for assimila- 
tion, (b) It is not dissociated by the gastric juice into the astringent 
iron chloride, (c) It does not interfere with digestion, but has a notice- 
able effect in increasing the appetite, (d) It does not irritate the 
alimentary canal, (e) Its effect in increasing the red corpuscles and 
the haemoglobin is constant and progressive. (/) It has, aside from 
its blood-forming effect, a demonstrable tonic and reconstructive 
action, which can be explained only by a stimulating influence upon 
metabolism. 

Arsenic may be given with the iron or in its place; it acts on the 
blood-making centres; it should be given as in pernicious anaemia 
uninterruptedly, with gradually increasing doses, sustained doses, and 
then decreasing doses, for a period of four to six weeks. 

High altitude increases the number of red cells and the amount of 
haemoglobin. Phlebotomy, sweating and organotherapy (bone marrow, 
splenic and ovarian extracts), have been suggested. 

Dietetic Treatment. — Regular meals should be given at three-hour 
intervals. The amount of albumin should be increased, even in the 
obese. The heavy English breakfast with meat is the best one, because 
the albumins are absorbed and taken up by the tissues more rapidly 
than are fats and carbohydrates; according to von Noorden two to 
four ounces of meat should be given with some bread and a cup of 
coffee. In administering milk, care should be observed lest the appe- 
tite be spoiled, lest too much fat be deposited, and the stomach suffer 
atony. Equal parts of milk and cream should be given. Milk should 
be avoided in the obese. Alcohol is indicated in thin, rather than in 
obese individuals. Patients should always rest before and after eating. 
The patient should retire early. In thin subjects the diet should be 
concentrated, consisting of albumin, vegetables, fats, alcohol and milk 
at breakfast and at bed time, but without increase of the carbohydrates. 
Iron produces better results in such cases after limiting the amount of 
water to about one quart; the latter procedure of itself is said to be 
beneficial in chlorosis. Sweats may produce the same result. When 
there is much gastric disturbance, eight meals may be given at two- 
hour intervals, and fluid and solid meals should be alternated. Gastric 
disturbance disappears after administration of iron and increase in 
weight. Hydrochloric acid, strychnia and belladonna are helpful. 



PERNICIOUS ANEMIA 839 

Exercise may be prescribed in convalescence, but in moderate and 
severe cases the patient should rest in bed. Hydrotherapy, especially 
by cool rubbings early in the morning, is advantageous. Cold baths 
are to be avoided, because they produce chills, insomnia, and digestive 
disturbances. Marriage may help mild cases, but produces injurious 
results in the severe type. 



(B). PERNICIOUS ANOSMIA. 

Definition. — A primary anaemia, in which are observed progressive 
diminution of the red cells, with changes in their form and color, 
and reduction in the haemoglobin, without changes in the white cells; 
this form of ansemia is due to haemolysis and to defective haemogenesis; 
it is characterized by pallor, adynamia, oedema and cardiac symptoms, 
and usually results in death from vomiting, diarrhoea, hemorrhages, 
fever and exhaustion. It was described by Andral (1826) and Chan- 
ning of Boston (1832); Addison gave the best early description, and 
Biermer later drew attention to the subject. 

Etiology. — The disease occurs in 0.2 per cent, of cases, especially 
in the third and fourth decades of life, although also observed in other 
periods, as in nurslings, and very late in life. Baginsky could collect 
but 16 cases in children. Sixty per cent, occurs in males. Although 
called a primary or essential anaemia, some cases are undoubtedly 
secondary which may properly be included under this head, because the 
symptom complex is the same. Bothriocephalus, and anchylostoma 
anaemia present identical blood findings, symptoms, and pathology; 
not merely the parasite but also its toxins are causative. Pregnancy 
and the puerperium, in certain localities at least, are causative. Syph- 
ilis, poor hygiene, infectious diseases, as typhoid or malaria, and diar- 
rhoea, vomiting, repeated loss of blood, and oral or gastro-intestinal 
sepsis have been considered factors. The precise cause of the blood 
destruction (haemolysis) is not known. 

Symptoms.— 1. The Blood Changes (Sorenson, 1874). — The amount 
is decreased, several punctures often being necessary to obtain enough 
for the blood-count; it is often watery, or dark, or amber-colored in 
some instances. The specific gravity is low, even 1,027; the dry 
substance is reduced, even to 9 or 10 per cent, of the normal. There 
is an increase in the albumin in the individual red cell (hyperalbumin- 
aemia rubra, von Jaksch). The serum does not contain free haemo- 
globin, as has been asserted by Limbeck. If injected into normal 
individuals, the serum has a globulicidal action. In contrast to chloro- 
sis and secondary anaemias, the coagulability of the blood is decreased, 
and the blood may remain fluid for some time after death; Hayein 
holds that the rarity of blood plates and lack of retractility of the 
clot are the most characteristic features of pernicious anaemia. The 
hemoglobin is decreased; it is rarely more than 50 per cent, of the 
normal, and may be reduced to 10 per cent. In some instances severe 



840 DISEASES OF THE BLOOD 

symptoms may be present, with 65 to 70 per cent, haemoglobin, In 
contrast to other anaemias, the haemoglobin per corpuscle is proportion- 
ately increased, i.e., the color-index is more than one (even 1.75). 
Laache explains the phenomenon in that certain "red cells, especially 
giant forms, contain a large compensatory individual amount of haemo- 
globin, which is also true of the microcytes, but less so of normal-sized 
red cells. The relative increase of the haemoglobin per corpuscle 
is thus best explained, and Limbeck's assumption of a haemoglob- 
inaemia is not generally admitted. Schmidt, Ponfick and others of 
the Dorpat school, maintain that the free haemoglobin, acting on the 
white cells, produces a fibrin ferment, which causes fever, hemorrhage 
and capillary embolism. The red blood corpuscles are greatly reduced 
in number, the average being 1,200,000. Plate XIII. Patients often 
die when this figure is reached. Lower counts have been noted, 
as 143,000 (Quincke). Poikilocytosis is marked, the irregularity in 
form and size of the corpuscles being great; great deformities, as 
Litten's horse-shoe or pessary-shaped corpuscles are noted. The 
individual red corpuscle is above the average size, i.e., 11 to 13, even 
16 to 18 pi instead of 5 to 8/jl, the highest normal measurement. Megalo- 
cytes may be observed in number, with less marked or absent umbili- 
cation. Polychromatism is frequent. Megalocytes in pernicious 
anaemia are evidence of megaloblastic degeneration of the bone-marrow 
(but have been held as evidence of regeneration). The varieties of 
nucleated and non-nucleated erythrocytes are depicted in Fig. VIII, 
Plate XIV. Megaloblasts are found but rarely in large numbers, seldom 
more than six or eight being seen in a single preparation (Ehrlich); 
in rare cases they may be abundant, as just before death, whence 
their generally ominous significance; they may be absent for months 
or weeks at a time. Normoblasts occur in relatively light cases, espe- 
cially in the " blood crises" of von Noorden, but are not numerous. 
Microblasts are frequently absent and are not umbilicated ; their teleo- 
logic significance lies in the increase of the respiratory surface of cells 
thus afforded. Cell divisions are found. (Plate XIII, Fig. 3.) Granular 
deposits (staining with basophilic dyes), in the protoplasm are noted, as 
in malaria, cachexia, leukaemia and suppuration; according to Ehrlich, 
they are not due to polychromatophile degeneration but to nuclear 
degeneration. The cells may stain only at their margins. Decreased 
formation of rouleaux is observed as well as amoeboid movement of 
the red cells. The white corpuscles are decreased absolutely, the lowest 
record being 1,500; the polymorphonuclears are decreased. Leuko- 
cytosis is a distinct complication, is often ominous though not necessarily 
fatal, and indicates inflammation, suppuration, or pneumonia. Apart 
from complications, increase in the leukocytes may take the form of a 
lymphocytosis, the lymphocytes being relatively increased, even to 
62 per cent, of the total white cells. The leukocytes are readily in- 
creased in children in any variety of anaemia. Marked decrease of 
the eosinophiles is an unfavorable sign according to Neusser. Pernic- 
ious anaemia due to parasites shows increase in the eosinophiles from 






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PERNICIOUS ANEMIA 841 

1 to 4 per cent, (normal) to 6, 36 and even 50 per cent. (Walker). (See 
Plate XIV, Fig V). 

2. Subjective Symptoms. — The most marked are general weakness, 
muscular adynamia on exertion, vertigo, palpitation, dyspnoea and the 
ordinary signs of anaemia. 

3. Skin.— The skin presents a peculiar pallor, often of a lemon 
color, which is somewhat characteristic. Slight icterus is not infre- 
quent. The skin, usually dry, may become drenched upon exertion. 
(Edema is invariable, occurring especially about the ankles and eye- 
lids. It is usually not marked, but is obstinate and may produce 
pronounced general anasarca; it is due to vascular degeneration and 
permeability. Hemorrhages, usually punctate, are frequent in the skin 
and mucosae. Large hemorrhages are infrequent. Pigmentation is 
sometimes as marked as in Addison's disease. The author once saw 
herpes zoster, and once herpes along the crural nerve. Sometimes 
before death the skin emits a foul, cadaverous odor (Eichhorst). 

4. Metabolism.— The nutrition is generally good and the panniculus 
adiposus is maintained, because tissue waste is lessened and water is 
retained in the tissues. The weight and strength may finally decline 
with persistent vomiting and diarrhoea. Opinions differ as to the 
destruction of the albumins. In the urine, indican, putrescin and 
cadaverin are found. Haematuria and glycosuria are rare. Albumin- 
uria, due to tubular degeneration, is frequent. Albumosuria is some- 
times noted; urobilin is frequently increased, and this sometimes 
imparts a dark color to the urine and indicates haemolysis. The uric 
acid is sometimes increased. Leucin is almost constant and tyrosin 
not infrequent. The chlorides are decreased. Acetone and diacetone 
are sometimes found. The iron in the urine is sometimes increased, 
and the phosphates are greatly increased. Fever, present in 80 per 
cent, of cases, bears no constant relation to the severity of the disease. 
It may rise considerably; the temperature may fall below normal in 
the ante-mortem coma. The type is irregular. Its cause is ill-under- 
stood; it is probably due to the production of a ferment from the 
destroyed red cells, or according to Schmidt, Ponfick and others, 
from a fibrin ferment formed from the leukocytes (v.s.). 

5. The Circulation. — Palpitation, precordial anxiety and dyspnoea 
are observed, but sometimes only on exertion or excitement. The 
heart impulse is irregular, and fallaciously strong to the palpating 
hand. Its outlines are usually normal, save that some dilatation of 
the right heart may occur or hydrops pericardii develop. Frequently 
a blowing systolic murmur is heard, usually with a clear diastolic 
tone; the murmur is rarely diastolic. The second pulmonic sound is 
variable, sometimes accentuated. No parallelism exists between the 
degree of anaemia and the loudness of the murmur. Leube reports 
a number of cases of chlorosis and pernicious anaemia in which there 
was relative tricuspid insufficiency; the positive venous pulse was 
present but no cyanosis. A venous hum in the neck, carotid pulsation 
and thrills, a loud, clear systolic tone and murmurs and double tones 



842 DISEASES OF THE BLOOD 

over the peripheral arteries are often present. The pulse tension is 
decreased, and its rate increased, being rarely below 80 and usually 
ranging between 90 and 120. Anatomically the heart shows vestiges 
of hemorrhage, degeneration and atrophy. The fatty, "tabby-cat 
heart" is almost constant, though absent in some cases (Litten). 
Degeneration in the smaller vessels has been noted, especially in those 
of the brain. 

6. Digestive Tract. — Anorexia, distaste especially for meats, gastric 
achylia, pain, and sensitiveness throughout the alimentary tract are 
noted. The tongue and gums are sensitive, and circumscribed or 
punctate hemorrhages are often noted in them. Pain in the mouth 
and oesophagus is sometimes due to the administration of arsenic. 
The gums may ulcerate, erythema bullosum and other eruptions may 
occur. Vomiting is frequent in various stages of the disease, and is 
often continuous or incoercible ; the vomitus consists of food, greenish 
mucus, and sometimes traces of blood. Epigastric pulsation, moderate 
abdominal distention and decreased or suppressed secretion of hydro- 
chloric acid are observed. The author once saw expansile abdominal 
pulsation which was wrongly diagnosticated as aneurysm. The glands 
in the gastro-intestinal tract may atrophy, which probably toxaemic con- 
dition is coordinate with and not causal of, pernicious anaemia. The 
mesenteric glands are not infrequently enlarged. Constipation or often 
paroxysmal diarrhea may occur. The stools are not characteristic, 
although sometimes acholic from poor absorption of fat. Parasites 
or their eggs may-be noted. Leucin and tyrosin crystals are frequent and 
are caused by diarrhoea, but are not in any sense characteristic of the 
disease. Fermentation in the bowel (with indican in the urine), 
some oedema, hemorrhage and follicular swelling in the bowel are 
frequently observed. Some ascites is found in the terminal stage of 
the disease. A deposit of iron (siderosis) in the liver, in the outer and 
middle zones of its lobules, also in the spleen, marrow, kidneys and 
lymphatic glands, is usual, and results from haemolysis; it is very 
unusual in other anaemias. There is most hepatic siderosis in acute 
cases. The liver is often slightly swollen and tender. 

7. Blood-making Organs. — The lymph glands are not usually en- 
larged. The prevertebral haemolymph glands have been carefully 
studied by Warthin, who found their sinuses dilated and evidences of 
haemolysis in their tissue which was shown by increased phagocytosis 
and sometimes hyperplasia of the glands; Warthin holds that pernic- 
ious anaemia is a haemolytic disease caused by an unknown poison 
which stimulates the phagocytes of the spleen, lymph nodes and haemo- 
lymph glands to increased haemolysis. The bones are tender, especially 
over the sternum and tibia and sometimes painful, and their fatty 
marrow may become lymphoid; this is not characteristic of the dis- 
ease, for lymphoid transformation may occur in other forms of anaemia, 
in cachexia or in fevers; in pernicious anaemia the red cells of the 
marrow are abnormally large, abnormally dark from increase of the 
haemoglobin, and are oval rather than round. The bone changes were 



PERNICIOUS ANEMIA 843 

first described by Wood, Pepper and Tyson (1875). The spleen is 
not enlarged, save from accidental causes. 

8. Sexual Sphere. — The menses cease, otherwise no characteristic 
changes are observed. 

9. The Nervous System. — The psychical functions are decreased, 
the memory is weak, and psychoses, delirium, hallucinations, mania 
and intractable insomnia may develop, either temporarily or antecedent 
to the terminal coma. Sometimes improvement is noted after severe 
mental symptoms or coma, compared by Laache and von Noorden 
to a crisis. The pupils are rather wide, and sometimes their reflexes 
disappear. Paresis, apoplectiform attacks, cramps, convulsions, par- 
esthesia, aphasia, vertigo, or in women and children the hydrencepha- 
loid state may develop. The cord is more frequently involved than 
the brain. The weakness may amount to paresis, not due simply to 
muscular adynamia but to spinal changes. The picture may resemble 
tabes as concerns the eyes, patellar reflexes, ataxia, bladder and rectal 
changes, pains, anaesthesia and paresthesia ; or the symptoms of 
spastic spinal paralysis prevail, as increased reflexes and spastic 
paresis. Frank Billings in 36 personal cases finds two groups, one 
in which the nervous symptoms are slight, and a second in which 
they are so conspicuous as to even overshadow the anemia itself. 
He found early paresthesia in all his cases, usually in the hands and 
feet, sometimes in the mouth ; sometimes hyperesthesia or disturbance 
of the temperature sense; 10 cases were spastic and atactic; three 
had paraplegia with abolished patellar reflexes, in voluntaries, oedema 
and bed-sores; the sexual function was decreased in males, and 
amenorrhcea was regular in women; histologically he found a sclerosis 
of the posterior and lateral columns, which was most marked in the 
lower cervical and upper dorsal segments, was not always diffuse but 
sometimes focal, and involved chiefly the white substance, but did 
not invade the entire neuron, and was probably due to a toxin. 

The peripheral nerves present few symptoms. The discrepancy 
between the anatomical findings and the clinical symptoms is remark- 
able, i.e., there may be many symptoms with few autopsy findings, 
and the converse is also true; consequently it is probable that the 
spinal and nervous symptoms are less sequences of anemia than 
coordinate toxic manifestations. Anatomically, capillary hemorrhages 
and disseminated foci of softening may be observed in the brain 
and meninges. Degeneration is found in the upper part of the cord, 
or possibly throughout its length. The white substance suffers more 
extensively than the gray. Small foci of degeneration with some 
secondary connective tissue growth, occur about the bloodvessels, 
which foci may fuse into plaques of small size with secondary degen- 
eration, hence the symptom complex of a systemic disease; the changes 
usually occur in the posterior column, which rarely wholly escapes. 
The bloodvessels may suffer degeneration, widening, thickening or 
indeed obliteration. 



844 DISEASES OF THE BLOOD 

In the eyes, the general symptoms of anaemia occur; the patient 
thinks he sees floating spots; hemorrhages in the retina are almost 
constant; occurring on a pale background, with tortuous veins, and 
a strong light reflex from the vessels, the hemorrhages form a striking 
picture (see Plate VI, Fig. 9). They are punctate or larger and their 
resorption is infrequent. The other senses are obtunded; labyrinthine 
hemorrhage with vertigo is recorded. 

Clinical Course and Prognosis. — The pallor and weakness which 
are first observed increase insidiously, and later dyspnoea, weak heart- 
action, oedema, complete anorexia, langor and violent gastro-intestinal 
disturbance and finally capillary hemorrhages and fever develop; 
this vomiting and diarrhoea may at times resemble acute poisoning. 
In other instances remissions may occur with treatment or independ- 
ently of it, perhaps after violent gastro-enteric manifestations. The 
symptoms may partially or wholly disappear, as in Ehrlich's case, 
where the red cells in seventeen days rose from 1,340,000 to 4,115,000. 
According to Laache, in simple anaemia the red corpuscles gain more 
rapidly than the haemoglobin, but in pernicious anaemia, improvement 
increases both equally. The disease with remissions may cover a 
period of years, the longest duration being ten years. Death usually 
occurs within half a year. 

The prognosis is usually poor when megaloblasts are present in 
numbers or when the color index is over one. In some cases the 
blood is rapidly regenerated; and 200,000 new red cells may appear 
in the blood within a day. 

Cabot's description of the disease recognizes two forms. 

The Severe, Rapidly Fatal Type — and the Less Severe, Slow Type. 

(a) Extreme progressive anaemia. Remissions. 

(b) Color index high. Normal or low. 

(c) Red cells increased in size. Normal. 

(d) Degenerative changes. None. 

(e) Many megaloblasts. Many normoblasts, few megaloblasts. 
(/) Lymphocytosis. Normal ratio of the various white cells. 

Death usually occurs in coma or possibly from cerebral hemorrhage, 
or other rare complications, as valvular disease, gastric carcinoma, 
tuberculosis, nephritis, sepsis, sarcoma, or leukaemia. Pye-Smith col- 
lected 20 cases of recovery. According to Schauman, the mortality 
in the parasitic form is 17 per cent. 

Diagnosis. — No single finding is absolutely characteristic, though the 
pallor, apathy, adynamia, oedema, weak heart, retinal hemorrhages, 
maintained nutrition, and the blood findings are highly suggestive. 
The yellow color is very often described as icterus and mistaken for 
it. The increased diameter of the red cells may also be found in 
icterus, and Ewing states no importance should be attached to the 
increase of diameter, unless 33 per cent, of the red disks show it. 
Megaloblasts are highly suggestive. The diagnosis must be made from 
the negative, as well as from the positive findings. 



PERNICIOUS ANEMIA 



845 



Differentiation. — (a) From metastatic bone-tumors, in which the white 
cells are increased (not merely the polymorphonuclear but the neu- 
trophil and eosinophile marrow cells) ; (b) from parasitic anaemia, for 
which the stools should be examined for parasites and their eggs; (c) 
fever, if dominant, may suggest typhoid or meningitis ; acute endocarditis 
may be simulated by the fever, anaemia, heart murmurs and cardiac 
insufficiency of pernicious anaemia; (d) from latent carcinoma, the 
gradual cachexia, anorexia, nausea, vomiting, hsematemesis, and de- 
crease or absence of hydrochloric acid may suggest gastric carcinoma, 
but the blood examination with thorough physical examination usually 
determines the point; {e) spinal disease, Addison's disease, and hemor- 
rhagic pleuritis, are usually excluded with ease; (/) from other anwmias. 
The following is constructed after Cabot's table: 



Pernicious 

Anaemia. 



Chlorosis. 



Secondary Anaemia. 



Red Cells Number. 



Shape. 



Size. 



Haemoglobin. 



Staining. 



Nuclei. 



Rouleaux. 
Color index. 

Leukocytes. 

Lymphocytes. 
Myelocytes. 

Adult Leukocytes. 

Coagulation. 



Average num- 
ber 1,000,000. 

Poikilocytosis 
great, sausage- 
shape, etc. 

Average increased, 
some dark. 

Increased per cor- 
puscle yet many 
Ponfick's shadow 
corpuscles. 

Polychromatophile 
cells. 

Micro-, megalo-, 
normoblasts. 
Megalo- more 
numerous than 
normoblasts and 
constitute major- 
ity of nucleated 
R. B. C 

Not present, or 
decreased. 

High color index 
(not in chronic 
nor mild cases). 



W. B. C decreased, 
except in blood 
crises, hemor- 
rhage, suppura- 
tion. 



Lymphocytosis 
(relative). 

Small number 
only. 



Rarely increased. 
Usually de- 
creased. 

Slow. 



Rarely under 
2,000,000. 

Somewhat de- 
formed. 



Diminished, light 
colored. 

Reduced per 
corpuscle. 



Megaloblasts rare 
though recorded. 
Normoblasts 
more than 
megaloblasts. 



Index less than 1 
always low: lower 
than in secondary 



Usually normal. 



Lymphocytosis. 



Rare; less than 
in pernicious 

anaemia. 

Decreased. 



Findings as in chlorosis. May be 
1,000,000 or less, though rarely. 



Various, not increased. 



Rapid. 



Normoblasts far more than megalo- 
blasts in malignant diseases. 

Normoblasts common (more than in 
chlorosis). 



Relatively low (this rule does not hold 
positively). 



Polymorphonuclear leukocytosis in ma- 
lignant disease, when R. B. C are'low 
in number, e.g. one million, speaks^for 
secondary anaemia; positive of more 
value than negative findings (i. e. no 
leukocytosis). 

Rarely increased (no decrease). 
Myelocytes very rare. 

Usually increased. 

Often rapid. 



846 DISEASES OF THE BLOOD 

Aplastic anaemia may resemble pernicious anaemia in its low blood 
count, reduced haemoglobin or even its color index. It was named 
by Ehrlich because the bone marrow was white or yellow and aplastic. 
In the blood there are no evidences of regeneration such as nucleated 
red cells. The white cells may number only 200 per c.mm. and 80 to 
90 per cent, of them are lymphocytes. There may be hemorrhages, 
fever, or hyperplasia of the spleen and lymph glands. 

Leukanamiia (see Differentiation of Leukaemia). 

Treatment. — 1. Hygienic. — The patient should have absolute rest 
in bed, and if possible, should be in a warm climate. An excessive 
nitrogenous diet is usually given, which is unwarranted because it 
increases tissue waste; besides, patients have an instinctive disinclina- 
tion to nitrogenous foods, and albumins frequently produce diarrhoea. 
A vegetable diet is better tolerated, with bread, zwieback, beef tea, 
peptones, milk, honey, or porridge. Nutrient enemata are indicated 
in the gastric crises. In pregnant women, labor should not be induced. 

2. Hsematinic. — (a) Transfusion of defibrinated human blood has 
been practised (Quincke, Hoffman, Landos), though it is seldom 
beneficial. Human blood may be transfused in toto (Ziemssen). (b) 
Lepine recommends the physiological salt solution, based on Mara- 
gliano's findings that the serum in cases of pernicious anaemia has a 
globulicidal action on the red blood cells. The serum destroys the 
haemoglobin in pernicious anaemia (the blood of a patient clears in a 
test tube on standing). Salt solution should be given frequently, and 
acts temporarily on the serum, (c) Phosphorus is without value and 
iron is often injurious, (d) Arsenic, recommended by Bramwell, is 
said to have cured the disease, though most cases have not been fol- 
lowed out thoroughly; it is, nevertheless, the best remedy known. It 
probably acts by irritating the blood-forming centres. Birsch-Hirsh- 
feld explains its action by assuming that it operates in some way upon 
the serum, which in this disease, destroys the corpuscles, while Litten 
holds that it increases the number of white cells. 

Physiological Action of Arsenic. — (a) The smallest dose merely 
increases the appetite, (b) Small doses stimulate the appetite by gas- 
tric irritation, by increasing secretion and stimulating peristalsis; 
tissue waste and elimination of nitrogen is lessened. It is an altera- 
tive, increases the muscular strength and endurance, improves the 
quality of the blood, the complexion, sexual powers, and lung capacity. 
(c) Continuous administration produces constitutional effects, as puffi- 
ness of the eyes, which is first seen in the morning (Wier Mitchell); 
this may be followed by general oedema, due to vascular and some- 
times renal alteration. Administration should be stopped when puffi- 
ness is observed, (d) Large doses result in anorexia, nausea, diarrhoea, 
abdominal uneasiness or colic, and sympathetic headache. 

The circulation is stimulated by small doses. Arsenic is absorbed 
by the bloodvessels, and possibly unites with the red cells. Full doses 
lessen the force and rate of the heart, for they act directly upon the 
heart muscle. Arterial pressure is reduced by peripheral vasomotor 



ACUTE POST-HEMORRHAGIC ANEMIA 847 

paralysis. Respiration and digestion are stimulated by small and 
depressed by large doses, although some deny the stimulant action of 
any dose. Elimination is very rapid, and is effected mostly by the 
kidneys and intestinal mucosa, but also by the skin, bile, lungs, saliva, 
and mother 's milk. 

Administration. — Children tolerate large doses, though the aged 
stand the drug poorly, and their digestion suffers; after the fifth year, 
adult doses are given ; girls tolerate the drug better than boys. When 
susceptibility is marked, a few drops of laudanum may be added, but 
its administration should always be stopped when (a) the eyes become 
puffy, or (b) itch, and (c) the tongue becomes furred. It may be given 
in the following forms: — (i) Acidum arsenosum (now officinal as arseni 
trioxidum) gr. 35 p.c, with ext. glycyrrhizae and (black pepper) piper 
aa gr. iv ("Asiatic pill"). (See formula under Treatment of Valvu- 
lar Disease, page 428). (ii) Liquor potassii arsenitis (Fowler's solu- 
tion, 1786) ; for hypodermic use it must be sterilized, because fungi are 
likely to grow in it. Even with great care abscess may develop. 
Minims v equal gr. 2*0 of ac. arsenosum. Treatment should commence 
with min. iij and each day the dose should be increased a drop until 
minims x or xi j are given ; rarely can larger doses (nj^xv-xxv) be given, 
(iii) The cacodylate of soda (Clin) pills (aa gr. \) may be given one to 
five times daily. 

3. Symptomatic Treatment. — This includes opiates for diarrhoea, car- 
diants for weak heart, and dilute HC1 for gastric achylia. 



(C). SECONDARY AN-ffiMIA. 
1. Acute Post-Hemorrhagic Anaemia. 

Etiology. — It may result (a) from trauma of large vessels; (6) from 
post-partum hemorrhage, abortion, or tubal pregnancy; (c) from 
haemoptysis, aneurysm, cardiac disease, or tuberculosis; or from inter- 
nal aneurysmal ruptures, as into the pleura; (d) from carcinomatous 
ulcerations in the uterus, gastro-intestinal tract, etc. ; (e) from round 
ulcer of the stomach or duodenum; (/) from varicosities, as in the leg, 
stomach, or oesophagus, and liver cirrhosis; (g) from conditions of 
the blood, as epistaxis in typhoid; from pancreatitis, hemorrhagic 
states, or constitutional diseases. 

Symptoms. — 1. The blood is (a) hydrcemic, the loss of fluid being 
supplied by the tissues, and its specific gravity is lowered, (b) The 
red disks are reduced to 50 per cent., or even to 20 per cent., are often 
irregular in contour (poikilocytosis), pale and poor in haemoglobin; 
their diameter may be increased; generally there are some normo- 
blasts, (c) The hcemoglobin is lessened even more than the red cells. 
(d) The leukocytes at first show a moderate increase; the polymor- 
phonuclears are decreased, and the mononuclears increased. In 
sudden anaemia with rapidly resulting death, the red cells are seldom 



848 DISEASES OF THE BLOOD 

nucleated, and there is no leukocytosis, because the bone marrow 
makes no effort to regenerate the blood. (See Plate XIV, Fig. 3.) 

2. There is marked anosmia of the skin and mucous membranes. 
Some oedema results from chemical changes in the blood, or malnu- 
trition and increased permeability of the vessel walls. The pulse is 
weak, and becomes frequent with the least exertion. Nevertheless, 
the vasomotor system very readily accommodates itself to a loss of 
one-quarter of the blood volume; a greater loss produces cardiac 
weakness. Sometimes the heart action seems more violent and respir- 
ation deeper and more rapid than normal. 

3. The digestive glands are less active. 

4. Albuminuria develops in a few hours after a large hemorrhage. 
No obvious microscopic change in the renal epithelium is detected, 
whence it seems that albuminuria is due, either to undue permeability 
of the renal vessels, or possibly, to albumins absorbed from the tissues. 

5. The nervous and eye symptoms may be marked. Amblyopia and 
amaurosis were known to Hippocrates; they are at first functional, 
but usually 8 to 10 days later degeneration or inflammation of the 
retina develops; as the blood pressure rises, retinal hemorrhages may 
follow. The patient often sees spots before the eyes. Occasional 
nervous manifestations include aphasia, or vertigo; delirium and 
hallucinations are chiefly terminal events; in some cases, lasting 
psychoses develop. 

6. The autopsy findings in fatal cases are fatty degeneration, par- 
ticularly of the heart, endothelium of the vessels, liver, brain, stomach, 
and kidney cells, which is usually caused by imperfect oxygenation. 
Hemorrhages in the uterus, gums, and retina, are due to impaired 
nutrition of the vessel walls. The bone marrow changes from a yellow 
to a red color, and abounds in normoblasts. 

Prognosis. — The patient may survive the. loss of more than one- 
third or one-half of the blood ; Hayem reports recovery after the num- 
ber of red cells fell to 550,000. Men stand hemorrhage better than 
women and young children, though the loss of a pint may cause death 
in arteriosclerotics. Recovery is more rapid in acute than chronic 
hemorrhage. In moderately severe hemorrhage, recovery may be 
practically complete within a week; water and albumin are readily 
yielded to the blood by the tissues ; the red cells regenerate more slowly, 
and the haemoglobin is the last element to reach normal. Increase in 
the coagulability of the blood is a favorable prognostic. According to 
Bierfreund, a loss of 10 to 15 per cent, of the blood is restored in eight 
days; of 16 to 20 per cent., in twenty days; of 21 to 25 per cent., in 
twenty-two days, and of more than 25 per cent., in twenty-nine days or 
more. 

Treatment. — This has been considered under gastric ulcer, and 
intestinal hemorrhage in typhoid; the essentials are absolute rest, 
morphine to insure quiet, and salt infusions only in case of extreme 
cardiac failure. 



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PLATE XIV. 

BLOOD. 

(Ehrlich triple stain.) 
(Prepared by Dr. I. P. Lyon.) 

Fig. I. TYPES OF LEUCOCYTES. 

a. Polymorphonuclear Neutrophile. b. Polymorphonuclear Eosinophile. c. Myelocyte 
(Neutrophilic), d. Eosinophilic Myelocyte, e. Large Lymphocyte (large Mononuclear). 
/. Small Lymphocyte (small Mononuclear). 

Fig. II. NORMAL BLOOD. 
Field contains one neutrophile. Reds are normal. 

Fig. III. ANEMIA, POST-OPERATIVE (secondary). 

The reds are fewer than normal, and are deficient in haemoglobin and somewhat 
irregular in form. One normoblast is seen in the field, and two neutrophiles and one 
small lymphocyte, showing a marked post-haemorrhagic anaemia, with leucoeytosis. 

Fig. IV. LEUCOCYTOSIS, INFLAMMATORY. 

The reds are normal. A marked leucoeytosis is shown, with five neutrophiles and 
one small lymphocyte. This illustration may also serve the purpose of showing the 
leucoeytosis of malignant tumor. 

Fig. V. TRICHINOSIS. 
A marked leucoeytosis is shown, consisting of an eosinophilia. 

Fig. VI. LYMPHATIC LEUKEMIA. 

Slight anaemia. A large relative and absolute increase of the lymphocytes rehiefly 
the small lymphocytes) is shown. 

Fig. VII. SPLENO-MYELOGENOUS LEUKEMIA. 

The reds show a secondary anaemia. Two normoblasts are shown. The leucoeytosis 
is massive. Twenty leucocytes are shown, consisting of nine neutrophiles, seven myelo- 
cytes, two small lymphocytes, one eosinophile (polymorphonuclear) and one eosinophilic 
myelocyte. Note the polymorphous condition of the leucocytes, i.e., their variations 
from the typical in size and form. 



Fig. VIII. VARIETIES OF RED CORPUSCLES. 

a. Normal Red Corpuscle (normocyte), b, c. Anaemic Red Corpuscles, d-g. Poikiloeytes. 
h. Microeyte. i. Megaloeyte. j-n. Nucleated Red Corpuscles. j,k. Normoblasts. I. b 
blast. m,n. Megaloblasts. 



CHRONIC SECONDARY ANEMIA 849 



2. Chronic Secondary Anaemia. 

Etiology. — Its possible causes are numerous; the chief types are 

(a) hemorrhages like those listed under acute post-hemorrhagic an- 
aemia, but frequent and persistent, as chronic hemorrhoidal bleeding. 

(b) Poor hygiene; overwork, long hours in poorly-ventilated, sunless 
offices or factories; insufficient food, or food poor in iron; or worry. 

(c) Exhausting discharges, or loss of albumin, as frequent pregnancies 
with prolonged lactation, albuminuria, respiratory or alimentary 
catarrh, or protracted suppuration, with its attendant loss of nuclein. 

(d) Toxemias; acute infections, as typhoid, diphtheria, rheumatism, 
or malaria, in which the activity of blood-making centres is diminished, 
and food is poorly assimilated; chronic infections, as syphilis and 
tuberculosis; gastro-intestinal, and possibly other intoxications; neo- 
plasms acting as mechanical obstructions (as those of the oesophagus, 
or pylorus), affecting sometimes, the bone marrow by metastases de- 
posited there, sometimes causing repeated losses of blood or elaborat- 
ing toxins, which break down the tissue albumins; in neoplasms the 
reduction of the blood in red cells and haemoglobin averages 55 to 66 
per cent, of normal; parasites (oxyuris, ascaris, echinococcus, etc.); 
and poisons (alcohol, lead, arsenic, or phosphorus) may produce 
anaemia. 

Symptoms. — The blood is pale, and its specific gravity is lowered. 
As a rule the red disks and haemoglobin are reduced in rather close 
parallelism, though occasional exceptions occur. The haemoglobin 
may fall to 18 or 14 per cent, of normal, and the red cells may, in rare 
instances, approach the count of pernicious anaemia. The red cells 
stain unequally, and their umbilication is clearer, so that the haemo- 
globin may even appear as a slight peripheral ring. They show less 
poikilocytosis than in acute post-hemorrhagic anaemia, and many of 
them are undersized. Some nucleated erythrocytes appear, but less 
than in the acute post-hemorrhagic form. The white cells vary with 
the causal conditions. As a rule, the polymorphonuclear neutrophiles 
are increased, and the eosinophiles (normally 4 to 6 per cent.), are 
decreased. The latter are often increased in parasitic anaemias, up to 
10, or even 50 per cent. In some chronic anaemias, the leukocytes are 
diminished. 

As to general symptoms, it is frequently difficult to decide whether 
they result from the anaemia, or from its cause. An anaemic skin, mus- 
cular adynamia, irritable weakness, and a tendency to oedema and 
hemorrhage into the skin, mucosae, and serosae, may be noted. The 
appetite is poor or easily satiated, and tenderness over the stomach, 
cardialgia, nausea, and decrease or increase of the HC1 may be ob- 
served. The intestinal functions are usually normal, though the motor 
power may be tardy. The aromatic sulphates of the urine are fre- 
quently increased. Rather exceptionally symptoms resembling those 
of pernicious anaemia may develop, as alteration of the bone marrow, 

54 



850 DISEASES OF THE BLOOD 

fatty heart, cerebrospinal degeneration, atrophy of the gastro-intestinal 
cells and retinal hemorrhage. The differentiation from primary 
anaemias has been considered under pernicious anaemia. 

Treatment. — The treatment expends upon the cause, for which 
thorough and repeated search should be made in doubtful cases. The 
hygiene of the home and place of work should receive consideration. 
Fresh air, sunlight, and proper food are often difficult to obtain for the 
lower classes. Iron and arsenic are valuable in simple types (y. 
Chlorosis and Pernicious Anaemia). 



(D). LEUKEMIA. 

Definition. — Leukaemia (leukocythaemia) is a disease of haemogen- 
esis, characterized by an increase of the leukocytes, a decrease in the 
red cells and haemoglobin, hyperplastic alteration of the bone marrow, 
lymph glands, and spleen, and by secondary infiltration into various 
organs and tissues. It was discovered by Bennett, and independently 
by Virchow (1851). 

Classification. — The older classification embraced (a) the splenic, 
and (b) the glandular (Virchow) types to which Neumann added (c) 
the medullary form; Behier described (d) a gastro-intestinal form, and 
Phillippart, Xachter, and Kaposi (e) sl dermal variety. This classifi- 
cation is clinical, but that of Ehrlich is based on the blood findings; 
the splenic form is not recognized by him, and he classifies the disease 
as follows : 

1. Lymphatic leukaemia, (i) The acute form, which runs a very 
rapid course, and resembles an acute infection, with lymphaemia, 
moderate or no splenic enlargement, fever, hemorrhages, lymphatic 
enlargement, and stomatitis, (ii) The chronic form, with lymphaemia, 
enlarged spleen and glands, and a protracted course. 

2. Myelogenic leukaemia with great polymorphism in the blood 
findings (v.i.). 

Acute Lymphatic Leukaemia. 

Acute lymphatic leukaemia (acute lymphaemia) includes nearly all 
acute leukaemias. The term does not imply that the lymph glands 
alone are the cause, because there is considerable and growing evidence 
that the bone marrow may be the seat of the causal change, and that 
it may contain a parent cell for both leukocyte and lymphocyte. The 
chief pathological finding is hyperplasia of the lymphadenoid tissue. 
The course is that of a rapid infective disease, usually with an acute 
onset, lymphaemic blood findings, asthenia, and often fever; it is fatal 
in a few days to a few weeks. The disease occurs at any age, but espe- 
cially in children, and 66 per cent, of cases are in males. The bacterio- 
logical findings are inconstant; the amoeba described by Lowit lacks 
confirmation, and is considered an artifact by most haematologists. 






ACUTE LYMPHATIC LEUKEMIA 851 

The disease is infrequent; Fussel and Taylor have collected but 56 
cases, but it is certain that many cases escape detection. 

Symptoms. — Prodromal symptoms may be observed, as headache, 
pain in the neck, spleen, joints, or head, epistaxis, mental obscuration, 
dyspnoea, or stomatitis, after which four cardinal findings develop : — 

1. Evidences of lymphadenoid change are observed, as lymph gland 
intumescence, which is very frequent, although not invariable, is 
usually moderate, and sometimes disappears after the initial swelling; 
splenic enlargement occurs in 66 per cent., and is of slight degree, save 
in children, in whom it may be enormous; tonsillar hypertrophy occurs 
in 50 per cent., sometimes with hemorrhage and necrosis. Reed 
recently published a case of acute lymphsemia without glandular en- 
largement. 

2. Hemorrhages are most characteristic and frequent; they occur 
(a) in the skin, as petechias or larger effusions, with necrosis or ulcera- 
tion in areas of lymphsemic infiltration; (b) in the mouth, gums, palate, 
and pharynx, as petechias, erosions or extensive necrosis, developing in 
areas of lymphsemic infiltration; (c) in the retina in practically 100 
per cent, with the same anatomical basis; (d) visceral hemorrhages, 
in the brain, cerebral nerves, labyrinth, and spleen; (e) from mucous 
surfaces, the vagina, urinary passages, and intestines; and (/) from 
the serous membranes. 

3. Necrosis in the infiltrated foci of the mouth occurs in 70 per cent., 
and is per se highly suggestive in the diagnosis (Bradford and Shaw) . 

4. Lymphwmia is the crucial finding. The ratio between the white 
and red cells is 1 to 2, 10 or 20, though the absolute number of lympho- 
cytes may reach 918,000 to the cubic mm. In general, the increase of 
leukocytes is less than in the splenomedullary form, and averages 
350,000. The polymorphonuclears are usually normal or decreased, 
the eosinophiles constitute about 1 per cent, of the white cells, a few 
myelocytes may be found, but the salient increase is in the lymphocytes, 
and chiefly in the larger forms ; the lymphocytes may constitute 90, or 
even 99 per cent, of the leukocytes. The red cells vary between 1 and 
3 million, and some nucleation occurs (although frequently absent, 
Wertheim, Hay em, Neumann, Rieder). The hsemoglobin usually falls 
below 50 per cent., or much lower in peracute cases. (For varieties of 
leukocytes, see Plate XIV, Fig. I. For blood picture see Plate XIII, 
Fig. 2 and Plate XIV, Fig. VI.) 

Other findings are pallor, frequent pulse, priapism, swollen and 
infiltrated liver, increased flow of urine, with increased urea and uric 
acid (increased nuclein destruction); albuminuria, nephritis and endo- 
carditis are sometimes observed. Edsall found the nitrogen output 
enormously increased (from autolysis). Lymphomatous masses may 
cause dyspnoea. The fever is irregular, both in type and occurrence. 
Intercurrent sepsis reduces the splenic and lymphatic enlargement, 
the white cells decrease even to normal, and sometimes an ordinary 
polymorphonuclear leukocytosis replaces the typical blood findings. 
The bone marrow is constantly involved, especially in the long bones; 



852 DISEASES OF THE BLOOD 

it is mostly red and jelly-like in color, more rarely red-gray, and is 
the seat of hemorrhage. The typical granular neutrophile myelocytes 
are few, while large and small lymphocytes abound as in the circu- 
lating blood; this is known as "the lymphoid marrow." Opinions 
vary as to whether the lymphatic or the medullary lesions are the 
primary change. Lymphatic deposits occur in the mouth, stomach, 
intestines (simulating typhoid ulcers), muscles, liver, kidneys, and 
thymus. The patient is usually emaciated. Fatty and degenerative 
changes in the heart and other viscera are observed. 

Diagnosis. — Though the splenic and lymphatic enlargements, 
petechia?, stomatitis, fever, ulceration and hemorrhages are frequently 
most suggestive, the blood findings alone are distinctive; they exclude 
typhoid, purpura, scurvy, trichinosis, erythemata with mouth changes, 
diphtheria (for which lymphaemia is often mistaken), septicaemia, 
severe acute anaemias, and chloroma (v.i.). 



Chronic Lymphatic Leukaemia. 

Chronic lymphatic leukaemia is rarer even than acute lymphaemia, 
and runs a clinical course of from months to years, with lymphadenoid 
hyperplasia and lymphaemia; it is closely associated by some writers 
with malignant lymphoma and Hodgkin's disease. (Thus Pinkus 
describes (a) the genuine lymphatic leukaemia with marked lymphaemia 
and (b) lymphatic pseudoleukemia with no striking disproportion 
between the number of red and white cells, but with a relative increase 
of the lymphocytes compared with the other white cells. Pinkus* 
views have not yet attained general recognition and confirmation.) 

Etiology. — No uniform or constant bacteriological cause has been 
proven. Lowit described an amoeba (haemamoeba leukaemiae parva 
[vivax]), which most authorities consider an artefact. 

Symptoms. — The symptoms begin insidiously and the disease may 
be first detected by (1) swelling of the lymph glands, usually in the 
neck, which may reach enormous dimensions. The axillary glands 
are large, though the inguinal are less massive; glandular swelling, 
as a rule, extends from above downward. Sometimes the internal 
glands alone are swollen, and in very rare cases the lymphatics are not 
enlarged. The glands are discrete without periadenitis, are oval and 
soft, being much less hard than in pseudoleukaemia. Sometimes 
moderate pain is experienced and there may be compression of vital 
structures, as the vagus, trachea, and portal vein. The glands continue 
to grow until death, unless an intercurrent affection as erysipelas, 
causes them to shrink temporarily. 

2. Splenic hyperplasia and intumescence is practically constant, 
though generally less extreme than in the myeloid type, or in Hodgkin 's 
disease. The spleen often projects from beneath the costal arch but an 
inch or so, it grows as the disease progresses, and is usually propor- 
tionate to the duration of the disease. In a case of Virchow, the spleen 



CHRONIC LYMPHATIC LEUKEMIA 853 

was not enlarged. Intercurrent sepsis, cholera, erysipelas, etc., may 
cause the splenic tumor to temporarily disappear, together with the 
lymphsemia and the lymph nodes, but all three findings may persist in 
such infections. Diarrhoea, and treatment by arsenic or quinine, may 
likewise effect splenic reduction. Perisplenic adhesions and thickening 
are common, and the organ is soft or hard according to the duration 
of the disease. The tonsils are often swollen, in which hemorrhages, 
with or without necrosis, are frequently observed. 

3. The changes in the bone marrow cause few symptoms; pain is 
rarely found. The essential character of the marrow alteration is 
undetermined. 

4. The blood reveals an absolute and a relative lymphamiia. The red 
and white cells may have a ratio of 100 to 1, and yet the lymphocytes 
constitute 90 to 99 per cent, of all the white cells. They are mostly 
small lymphocytes (Pinkus), whereas the larger forms occur in the 
acute lymphatic leukaemia. (Ehrlich holds that large lymphocytes 
predominate.) Many of them are altered, degenerated, or swollen. 
The neutrophile polymorphonuclears (normally constituting 70 per 
cent, of the white cells), are reduced to 10, or even 2, or 1 per cent. 
Myelocytes are usually absent. The red cells average 4,000,000, but 
may reach 2,000,000, and seldom lower. The lymphocytosis may 
temporarily disappear during infection, and in one instance this was 
permanent. (See Plate XIV, Fig. 1.) 

5. The skin may itch or be the seat of papular eruptions, or urticaria. 
Lymphomata form in the skin, sometimes of considerable size; or 
infiltrated reddish deposits may precede the lymphsemic blood findings. 
(Edema occurs, while hemorrhages are rarer. Facial growths are 
observed similar to those of chloroma (v. Medullary Form, Diag- 
nosis), or to the symmetrical swelling of the lachrymal and salivary 
glands. 

6. The heart is degenerated, as are the vessels, from all of which 
hemorrhages may occur, as in the acute type. Intraperitoneal hemor- 
rhages from ruptured adrenals are often reported. The nerve trunks 
may degenerate with bulbar, spinal, and nerve trunk symptoms. 
Retinitis leuksemica or optic nerve involvement may impair vision. 
The liver is swollen from degeneration, and from lymphatic infiltra- 
tion. Dyspnoea is most common, and occurs early from the anaemia, 
mechanical compression of the air tubes, vessels or nerves, or from 
leukemic changes within the follicles of the mouth and air passages. 
Renal infiltration is frequent. 

Course. — The course of the disease is slow; it develops gradually 
and passes slowly into cachexia, though now and then extension in 
the glands is "explosive" (Trousseau). Remissions and intermissions 
of weeks or months are not uncommon. Intercurrent disease may be 
fatal, as pneumonia, and mechanical stasis, suffocation and acute 
exacerbations of the disease itself mav hasten the course. 



854 DISEASES OF THE BLOOD 

Diagnosis. — The diagnosis, suggested, perhaps by the skin lesions, 
lymphomata, splenic enlargement or hemorrhagic tendency, is posi- 
tively made only by the blood examination. 



Myeloid Leukaemia. 

Myeloid leukcemia (myelaemia, myelogenic or medullary leukaemia), is 
the most common form of leukaemia, and occurs for the most part be- 
tween the twentieth and fiftieth years ; 67 per cent, of cases occurs in 
males. Bacteriology has shown no cause, and Lo wit's theory concern- 
ing the haemamoeba leukaemias magna, has been vigorously contested. 
The disease is frequent among the Polish Jews, and the poorer and 
working classes. A history may be obtained of malaria, syphilis, ty- 
phoid, influenza, stomatitis, tonsillitis, digestive disturbance, pregnancy, 
disturbed menstruation, the climacteric and trauma, though they are 
probably only accidental occurrences. The disease has been noted in 
three generations. Leukaemia has been also observed in the horse, 
dog, cow, pig, and cat. 

Symptoms. — 1. Blood. — The specific gravity is decreased from 
1,055 to 1,045-36; it is watery, or sometimes chocolate-colored; it 
coagulates slowly (on account of the peptone present from the white 
cells, although observations differ on this point). In extreme cases the 
coagula are white (leukaemia) or slightly greenish. Large white clots 
are observed at autopsy, and Virchow thought that he had incised an 
abscess when he opened the left ventricle in his first autopsy. Acidity 
develops after puncture from lecithin and glycerophosphate acid. 
Microscopically the white cells are enormously increased, even as much 
as 1 to 1, or in Robin's case, 2 whites to 1 red cell. The highest 
count which the author has seen was in Mercy Hospital in 1904; the 
whites numbered 950,000, and the reds 1,900,000 (1:2). Sometimes 
one must even look for the red corpuscles. Amoeboid movement is 
greatly decreased. (Plate XIV). 

The characteristics of the white cells are : (a) The large mononuclear 
neutrophiles ("mark cells," myelocytes), which are found early, and 
amount to 30 per cent, or more of the leukocytes. In themselves they 
are not absolutely pathognomonic, having been found (in small num- 
bers) in pneumonia, uraemia, chlorosis, skin diseases, syphilis, and in 
normal blood, (b) Mononuclear eosinophils, which occur in other 
diseases, but in myeloid leukaemia are absolutely increased, though not 
necessarily relatively increased. They are absolutely necessary to the 
diagnosis, (c) The "mast cells," which must be absolutely increased; 
they are polymorphonuclears with basophile granulations, which do 
not show with the tri-acid stain. Often they are relatively increased, 
from 0.28, the normal percentage, to 1, or indeed, 18 per cent. They 
are constant in this type, (d) The polymorphonuclear neutrophiles 
and eosinophiles, which are sometimes increased, but are more often 
normal or decreased, (e) Atypical leukocytes, dwarf forms and white 



MYELOID LEUKAEMIA 855 

cells containing mitoses, fat globules, or red cells, may also be found. 
(See Plate XIV, Fig. I.) 

The red cells are, as a rule, decreased to two or three million, though 
leukaemic patients are not always anaemic and an excess of red cells has 
been described by Quincke and Litten. Toward the end the red cells 
may decrease to even 300,000, and thus resemble pernicious anaemia. 
The reds may become degenerated, necrotic, polychromatic, or acquire 
amoeboid movement, nuclei, and mitoses. Nucleation occurs more 
frequently than in any other anaemia (Ehrlich), normoblasts being the 
most common form. The haemoglobin tends to crystalize. The color 
index is 1, or less than 1 (0.5 to 0.7). (See Plate XIII Fig. I. and Plate 
XIV, Fig. VII.) 

2. Splenic Enlargement. — This is usually the first symptom to attract 
attention; it appears with the blood findings and is most constant; 
spleniculi, if present, are enlarged. Instead of a weight of 5 to 7 ounces, 
18 to 28 pounds are reported; from the normal measurements, 3 to 5 
inches, dimensions of 15 inches are frequently observed. Splenic pul- 
sation was observed by Gerhardt. The form of the organ is preserved. 
The size varies (a) during intermissions; (6) without cause; (c) from 
administration of arsenic and quinine, and (d) from diarrhoea or hemor- 
rhages. It is enlarged after meals. A systolic murmur is sometimes 
heard. The notches are usually clearly palpable, and the edges are 
plump, rounded, and hard. Crackling under the fingers and tenderness 
indicate soft adhesions (perisplenitis). Firm adhesions may develop 
and the capsule may thicken. Though at first soft, it later becomes 
very firm. The pulp and trabeculae hypertrophy, and new lymphoid 
deposits are clearly marked against the reddish pulp. It may reach 
to the navel, or into the pelvis, displacing other organs. Pruss and 
Westphal, on puncture, found the Charcot-Neumann crystals. The 
author has seen three cases of leukaemic floating or wandering spleen, 
two of which had been operated on as uterine tumors. Rupture is a 
rare complication. 

3. Glands. — The glands are enlarged in 33 per cent. According to 
the most recent views, the glands are heteroplastic, due to new-formed 
myeloid tissue, " metastases" from the bone-marrow. Though soft 
at first, they later become hard. Caseation and suppuration are most 
infrequent. As in the other types of leukaemia, recurrent compression 
of the vagus, trachea, portal vein, and bronchi, may result. Retro- 
sternal dulness has been observed. 

4. Bones. — Bone changes, recognized first by Neumann, occur in 
the spongy and long bones (ribs, tibia, sternum, and vertebrae). The 
bone is mostly rarefied and there may be tender places, or yielding areas 
which are more important than tender ones. The histological changes 
in the marrow are (a) the lymphoid (Neumann), in which the marrow 
resembles currant jelly, is reddish, and consists of small lymphocytes; 
it is sometimes hemorrhagic; the normal fatty appearance disappears. 
(b) The fyoid; which is seen mostly in the myelogenic type; the mar- 
row is not transparent, but gray; its cells are rich in protoplasm with 



856 DISEASES OF THE BLOOD 

one or many nuclei. In both forms nucleated red cells abound, also 
eosinophile cells, large cells with neutrophile granules and large 
nuclei. 

5. Vascular System. — The heart is moderately distended with white 
clots, and as Virchow described in his first autopsy, opening the heart 
was like incising an abscess. The muscle is pale and fatty, and nodules 
of leuksemic infiltration in the myocardium, foci of hemorrhage, and 
pericardial nodes and transudation are frequent. Cardiac disloca- 
tion from pressure by enlarged glands and spleen, ansemic bruits, 
venous pulsation, bruit de diable, palpitation, systolic murmurs from 
pressure by the glands on the vessels, and centripetal venous pulse 
(Senator) are observed. The radial pulse is rapid, and either soft or 
tense. Dyspnoea results from weak heart, vagus pressure, nodules in 
the lung, bronchitis, hydrothorax, pressure of the spleen on the dia- 
phragm, tilting of the heart upward, and compression by the glands. 

6. Respiratory Tract. — Nodules are frequently seen in the larynx, 
trachea, thyroid, and thymus, often with hemorrhage, sometimes 
resulting in tracheal, bronchial, or laryngeal stenosis. In the lungs 
(Deiter) lymphoid nodules may necrose and cavities like those of 
caseous tuberculosis (Boettcher) may appear. Small myeloid foci of 
leukocytes may resemble miliary tuberculosis (Virchow). Bronchitis 
with many eosinophile cells in the sputum, nodes along the pleural 
vessels, and pleural hemorrhage, transudation and exudation have 
been observed. 

7. Fever. — Fever is less frequent than in the acute type, but occurs 
in the majority of cases. It is rarely high; temperature may be normal 
for months, or it may resemble recurrent fever, typhoid, sepsis, or 
malaria, though it follows no one type. 

8. Digestive Canal. — Anorexia, thirst, stomatitis, or pharyngitis 
with ulceration of the lymphoid deposits, dysphagia from glandular 
pressure on the oesophagus, eructations and vomiting are occasional 
symptoms. Diarrhoea is very common, leucin and tyrosin being found 
in the stools. An enteric type is described by Behier and others, in 
which the bowel symptoms are conspicuous; the lymphadenoid struc- 
tures in the ileum are prominent, and Friedreich once confused this 
type with typhoid on account of the ulceration, enlargement of the 
spleen, and hemorrhage from the bowel. The abdominal lymph 
glands may be enlarged, though the others may remain normal. The 
liver is much enlarged, especially when the spleen is enlarged. In 
Welch's case it weighed 13 pounds, and in another it weighed 25 
pounds. Its surface is smooth, its consistence increased, and its edges 
plump. Myeloid proliferations or deposits occur in the liver as in the 
spleen, and dislocate or deform the rows of liver cells. The portal 
lymph nodes may be enlarged. Icterus is infrequent and ascites is 
common from cachexia or lymph nodes (leuksemic peritonitis). The 
fluid contains many white cells and the myelocytes predominate as in 
the blood. 



MYELOID LEUKEMIA 857 

9. Kidneys. — The kidneys are frequently involved; there may be 
"myeloid" infiltration and cloudy, fatty, and amyloid alteration. The 
urine is decreased, pale, and strongly acid. The uric acid (Virchow) 
may amount to 45 to 105 grains (3 or 7 gm., Laache), though usually 
20 grains (1.5 gm.), (normally 8 grains, or 0.5 gm.). Normally uric 
acid is as 1:50-80 of urea, but in leukaemia, it is 1:16 (Salkowski). 
According to Stadthagen, the uric acid results, not from decreased 
oxydation of the albumins, but from increased formation of the acid. 
The xanthin bodies are increased. Albuminuria is usual only in the 
last stages. The amount of urea depends on the degree of cachexia. 
Priapism occurs from nervous causes, as hemorrhage, or from throm- 
bosis of the dorsal vein. Amenorrhoea is frequent in women. 

10. Nervous Symptoms. — Nervous symptoms may develop, as delir- 
ium, neuralgia, headache, syncope or vertigo, mania or rarely bulbar 
palsy, facial paralysis, apoplexy, or symptoms like those of brain tumor. 

The Eye. — Lymphoid nodules may develop in the orbit, possibly with 
exophthalmus. The retinitis leukcemica, first described by Liebreich, 
is not a genuine inflammation, but a leukemic infiltration and occurs 
in 25 to 33 per cent.; the retina is pale, its arteries small, and veins 
large; the papilla is "washed" and yellow, or orange colored spots 
with red borders appear; hemorrhages also occur (Plate VI, Fig. 9). 

The Ear. — Vertigo, deafness, tinnitus, and an atactic gait, may result 
from growths in the labyrinth; sudden deafness from hemorrhage is 
described by Steinbruegger, Pepper, Wagenhausen, and Lanois; the 
author saw three such cases within one year. 

11. Skin. — The skin is less involved than in lymphaemia, but there 
may be acne, pigmentation, oedema, pruritus, lymphoderma pernic- 
iosa, diffuse or tumor-like infiltrations, or sweats. 

12. Hemorrhages. — These are less frequent than in acute leukaemia 
or in pseudoleukaemia, though Mosler found them in 52 per cent. 
Epistaxis is the most common, and may be fatal. Stomach and bowel 
hemorrhages are next, and those from the respiratory, genito-urinary, 
and other tracts are rarer. They also occur in the skin, joints, muscles, 
subcutaneous tissues, or brain, where they may be single or multiple. 
The writer has seen three massive hemorrhages under the skin of the 
thorax, one in Leube's clinic, and two in his own practice. Death has 
followed the extraction of teeth (Chapelle) in a leukaemic subject. 
The writer saw Kolisko autopsy a case in which a slow ascending paral- 
ysis followed hemorrhage between the spinal pia mater and arachnoid. 

Complications. — Complications are nephritis, pneumonia, endo- 
carditis, amyloid degeneration, diabetes, and gangrene. Sussmann 
could collect but 25 cases of complicating tuberculosis; this number 
was increased by Dock to 27 ; at the time of writing, the author saw a 
case with E. W. Andrews, in which a left-sided tuberculous pleurisy 
developed; tubercle bacilli and mononuclear white cells were recovered 
from the blood-stained fluid. 

Diagnosis. — The diagnosis was formerly a matter of great difficulty, 
because the difference between leukaemia and leukocytosis was made one 



858 DISEASES OF THE BLOOD 

of degree only, and various limits were placed (as a ratio of 1 leukocyte 
to 50 erythrocytes), beyond which leukocytosis was said to cease and 
leukaemia begin. The mere number of white cells is no criterion, because 
a ratio of 1 to 15 or 20 may be leukocytosis (as in Strauss' case of 
gastric cancer), and on the other hand, 1 to 200 may be leukaemia 
(von Noorden). Leukocytosis from digestion, fasting, marasmus, 
pregnancy, acute infections, or in the death agony, is of the ordinary 
polymorphonuclear neutrophilic type. (Plate XIV, Fig. IV.) Leukocy- 
tosis is a symptom, but leukaemia is a disease. It is clear, then, that 
increase in the variety of white cells is the definitive test. The poly- 
morphism of the blood is striking; according to Lazarus, there must 
be (a) mononuclear leukocytes with granulations (myelocytes); (b) 
increased mono- and polynuclear eosinophiles ; (c) absolute increase 
in the "mast cells/' and (d) nucleated red cells must be readily found. 
The gross splenic, medullary, or lymphatic lesions are of but presump- 
tive value in diagnosis, and the polymorphic blood picture alone dif- 
ferentiates from pseudoleukaemia, typhoid, purpura, anaemia, sepsis, 
or malaria. Not only can the disease, but also its type, be recognized 
from findings in the blood. 

Special caution should be exercised in making a diagnosis (a) during 
remissions, when the blood is rarely morphologically normal, no matter 
what the number of leukocytes. In one of the author's cases, the leu- 
kocyte count dropped from 1,250,000 to 9,000 in a week, though the 
myelocytes still constituted 33 per cent, of the white cells, (b) Care is 
also necessary during acute infections when the leukaemic character- 
istics may disappear (but not always), as during typhoid, acute miliary 
tuberculosis, influenza, or sepsis, (c) The blood findings may become 
atypical just before death. 

Similar Conditions. — 1. Chloroma is considered a malignant type 
of leukaemia, or a "neoplastic hyperplasia of the red bone marrow," 
by Dock and Warthin, who in 1904, collated 39 cases. It is closely 
related to acute lymphaemia. Lymphomata form, causing orbital pain, 
tinnitus, deafness, temporal and orbital swellings, and such ocular 
symptoms as exophthalmos, strabismus and disturbed vision. The 
lymphomata are greenish, whence the name chloroma. It usually 
develops before the twentieth year. Retinal infiltration occurs with 
hemorrhages. Other findings are ataxia, pallor, sternal tenderness, 
hemorrhages, severe anaemia, often but not always changing to leu- 
kaemic characteristics, greenish urine, and greenish lymphomatous 
infiltration of the bone marrow, periosteum (sometimes with Charcot- 
Leyden crystals), the liver, or lungs, and greenish lymphadenoid 
changes. The haemoglobin and red cells are reduced, even to 15 per 
cent, and 500,000 respectively. The leukocytes number about 50,000, 
but have been as numerous as half a million ; they are chiefly lymph- 
ocytes. The affection is always fatal. 

2. Leukancemia is described by Leube as a severe blood disease, in 
which the myelogenous formation of both the red and white cells is 
disordered, i.e., it combines some features of both leukaemia and per- 



MYELOID LEUKEMIA 859 

nicious anaemia. Its features are (a) a progressive anaemia, waxy 
color, and asthenia; (b) numbers of normoblasts, but especially of 
megaloblasts ; (c) no abnormal pigments in the urine, no enlargement 
of the lymph glands (though since reported by Mattirolo), and no sider- 
osis of the tissues; (d) no true leukaemic blood findings, but consider- 
able myelocytosis and lymphocytosis; (e) firm connective tissue in the 
bone marrow, and (/) enlargement of the spleen, and prevertebral 
haemolymph glands. 

3. Secondary Cancer in Bone. — There are 13 cases in the literature, 
in which cancerous bone metastases have produced blood findings 
rather like those of pernicious ansemia and increase of the leukocytes 
(of which the myelocytes constituted 4 to 17 per cent.). 

Prognosis. — The prognosis of leukaemia is bad. The former reports 
of recoveries are not wholly reliable. It may last 5 to 8 or even 10 years 
after a diagnosis has been made. One-half to 3 years is the usual length, 
and a little over 1 year is the average course. The beginning is insidi- 
ous, and enlargement of the abdomen, dyspnoea, ansemia, and enlarged 
glands are the cause for seeking medical treatment. The nutrition is 
usually good. Sudden death may occur, either without discernible 
cause or from hemorrhage of the brain, haematemesis, marasmus, ana- 
sarca, diarrhoea, pleuritis, peritonitis, deep coma, pneumonia, or diar- 
rhoea. Remissions (as in pernicious anaemia) occur, but the blood 
findings persist. Ewing observed 3 acute cases, and Billings and Capps 
published 2 and collated 7 others from the literature (which resembled 
an infection with hemorrhages, moderate splenic and lymphatic hyper- 
plasia, severe anaemia, often necrosis of the throat and jaw, with 16,000 
to 540,000 leukocytes, and often with low fever). A permanent cure 
after erysipelas has been reported by Richter. 

Treatment. — Hygienic measures, rest and a careful diet, are of some 
benefit. Fats and carbohydrates cause dyspepsia, whence Litten gives 
animal foods, eggs, milk, raw chopped meat, koumyss, peptones, 
oysters, beer, wine, zwieback, spinach, Valentine's meat juice, and 
Brand 's meat extract ; an ice-bag to the spleen may mitigate pain over 
it. Splenectomy is most irrational, for leukaemia is a primary disease 
of the bone marrow. All of Collier's series of 16, and 94 per cent, of 
Bissel-Hagen 's group of 35, died. The great danger is that of hemor- 
rhage. Great caution must be observed in using purges, which, as in 
Addison's disease, may cause sudden collapse and death. Inhalations 
of oxygen, blood infusions, spleno- or organotherapy and iron are 
inferior to arsenic, which decreases the number of white blood cells, 
and the size of the spleen. Hemorrhages may disappear, and the num- 
ber of red cells increase. Ebert gives arsenic with quinine. It is injected 
locally (by Mosler) into the glands and spleen, but in the author's ex- 
perience, without success. Phosphorus may soften the glands. Special 
care should be employed in tapping an ascites, for peritonitis is prone 
to develop. The x-rays may prove decidedly beneficial. In 1 case 
already alluded to, the patient lived 19 months after the day he seemed 
to be dying. The way it helps is still a mystery. Schirmer says that 



860 DISEASES OF THE BLOOD 

72 cases are reported (1905), and Wendell thinks over 90 per cent, were 
benefited. In some cases, the glandular and splenic enlargements, 
and the blood findings have wholly disappeared, as in 1 case observed 
by the writer. The x-rays seem to produce a leukotoxic substance 
(Capps and Smith). 

(E). PSEUDOLEUKEMIA. 

Definition. — A disease resulting in chronic anaemia, or cachexia, 
of which the chief symptoms or signs are enlargement of the spleen, or 
lymph structures, or both. The definition of the disease as " leukemic 
appearance without leukaemic blood findings," no longer holds. Such 
conceptions would include glandular tuberculosis, Kundrat 's lympho- 
sarcomatosis, etc. It is also called Hodgkin 's (1832) disease, pseudo- 
leukemia (Cohnheim),adenia (Trousseau), lymphosarcoma (Virchow), 
malignant lymphoma (Billroth), and anaemia (cachexia), lienalis or 
lymphatica (Wilkes). 

Etiology. — The etiology is not clear. The disease occurs after local 
lymphatic disturbances in the neck, following otorrhcea, coryza, extir- 
pation of the glands of the neck, and tonsillitis. Like chloroma and 
leukaemia, it is observed chiefly (75 per cent, of cases) in males between 
twenty and thirty years of age. The disease is not uncommon in chil- 
dren, and often occurs in the lower animals. It also sometimes runs 
through several members of the same family. Malaria, syphilis, scrof- 
ulosis, alcoholism, rhachitis, diarrhoea, typhoid, measles, and scarlatina 
are often noted in the patient's history, but their relation, if any, is 
obscure. Suspected to be mycotic, many negative and variant exami- 
nations have been made. Though the disease has no well-established 
relation to leukaemia, as Cohnheim. held, yet Fleischer, Penzoldt, 
Mosler and Senator have observed transitions from pseudoleukemia 
to leukaemia. Neumann held that the leukaemic blood changes de- 
pended solely on the hyperplastic marrow changes, and that as long 
as the hyperplasia involves only the spleen and glands, pseudoleukaemia 
results. Sternberg and others have maintained that it is tuberculosis, 
a theory disproven by Dorothy Reed and Simmons. 

Symptoms. — Its types are (a) lymphatic; (b) lienal, pseudoleukaemia 
splenica, splenomegalia ; (c) mixed (a and b), and (d) myelogenic. 

1. Lymph Glands. — Swelling of the lymph glands is generally the 
earliest symptom; the cervical glands first become enlarged, perhaps 
after an otitis or tonsillitis. The axillary glands become enlarged 
after a variable period, then the inguinal and other groups. They are 
soft and elastic; at first, the individual glands are round, or oval, dis- 
crete, smooth, and clearly palpable; later, with increasing size, they 
fuse into harder, irregular masses as large as the fist, or a child 's head, 
particularly those in the neck. They may sometimes be painful from 
periadenitis, but never transcend the gland capsule, and seldom caseate 
or suppurate. From the neck, where the jugular veins may be com- 
pressed, the glandular enlargement often passes to the intrathoracic 



PSEUDOLEUKEMIA 861 

glands, which are more often enlarged than the other internal nodes; 
this often occasions dyspnoea, compression of the superior cava, 
(whence the development of a large collateral circulation on the chest- 
wall), dysphagia, bronchial compression, and recurrent, or vagus par- 
alysis. From the axillae, the glands under the scapulae and pectoral 
muscles enlarge. The veins of the arm may be compressed, causing 
oedema. In the abdomen the retroperitoneal, mesenteric, periportal, 
iliac, and other lymphadenoid groups, may enlarge greatly ; according 
to their location, abdominal pain, oedema of the legs, paraplegia, hydro- 
nephrosis, ascites, and jaundice may ensue. Histologically, the lymph- 
adenoid changes are (i) increase in the endothelial and reticular cells ; 
(ii) hyperplasia of the lymphoid cells; (iii) formation of peculiar giant 
cells; (iv) fibrosis and chronic inflammation, and (v) great increase of 
the eosinophile cells (Dorothy Reed). 

2. Spleen. — The spleen is enlarged in 75 per cent, of cases (Gowers). 
When enlarged, it reaches dimensions rarely attained in leukaemia, but 
maintains its form, is hard and tender, and presents the same histo- 
logical appearance as in leukaemia, viz., nodes of lymphoid cells in a 
fibrous reticulum. The greatest swelling of the spleen is usually 
observed when the lymphatic glands are large and hard, yet spleno- 
megaly may be the sole symptom. Some physicians doubt the correct- 
ness of the diagnosis when the spleen only is involved, but splenic 
hypertrophy alone, with relative increase in the lymphocytes, may be 
classed as Hodgkin 's disease according to Pinkus. 

3. Bone-marrow. — The bone-marrow is less frequently involved than 
in leukaemia. A myelogenous pseudoleukaemia has been recorded, 
but its exact status is still doubtful. The eosinophiles are abundant in 
the lymph nodes and bone-marrow. 

4. The Blood. — The ratio between the red and white cells is normal. 
The haemoglobin is decreased and the blood index is usually 1; the 
haemoglobin may be rapidly decreased as in Litten's case, from 85 to 
40 per cent, within a week. There is usually moderate anaemia, espe- 
cially in advanced cases. Poikilocytes and microcytes often occur; 
megalocytes rarely, and normoblasts sometimes are found, but the 
eosinophiles are not increased. The blood plates are increased, but the 
Charcot-Leyden crystals are never found. Concerning the white cells, 
there is a relative increase of lymphocytes, the chief criterion of the 
disease, according to Pinkus and Ehrlich. The polymorphonuclear 
neutrophiles are decreased. These changes may not be observed in 
the earliest stage of the disease. The total of white cells is not essen- 
tially increased; in the case of Askanazy, the disease was pseudoleu- 
kaemia for two and a half years ; when it became leukaemia, and lasted 
another one and one-half years. Limbeck found an increase in the 
polymorphonuclears in inflammation of the glands with fever, and the 
lymphocytes increased when the change was like that of lymphosar- 
coma. Leukocytosis may be explained in some instances as a leu- 
kocytosis of the death agony, or a terminal infection. Reineri found 



862 DISEASES OF THE BLOOD 

cases with decrease in the lymphocytes, which was caused by their 
decreased formation in the lymph glands. 

5. Other Organs. — (a) The urticarious eruptions and lymphatic 
growths in the skin occur rather more frequently than in leukaemia; 
the lymphoderma perniciosa of Kaposi (erythrodermie mycosique of 
French writers) may be considered a type of pseudoleukemia in cases 
with an absolute lymphocytosis. Erythema, purpura, furuncles, 
pemphigus, prurigo from irritation of the lymphatic deposits around 
the sweat glands, and pigmentation, have been observed. According 
to Dubreuilh (1905), 18 cases of prurigo are reported. Severe sweats 
are frequent, (b) Symptoms of anaemia occur, as a feeling of cold, 
vertigo, syncope, dyspnoea, oedema, hemorrhage, palpitation, ano- 
rexia, dyspepsia, and severe diarrhoea, (c) Local pain over the liver 
and spleen may indicate perihepatitis, or perisplenitis. Swelling of the 
liver may be marked, and is due to lymphoid deposits. Severe mus- 
cular pain has, in some instances, suggested trichinosis, (d) Gangre- 
nous stomatitis, or pharyngitis, may occur in degenerated lymph nodes 
in the mouth, tonsils, and throat. Gastric and intestinal ulcerations 
and sometimes perforation are noted, though they are less frequent 
than in lymphosarcoma. Neusser noticed gastric crises like those of 
tabes, (e) Ross and Osier described lancinating pains in the feet, and 
oedema from involvement of the spine and cava by the lymph nodes. 
(/) Amyloidosis, bronchial catarrh, and pulmonary phthisis have been 
noted, (g) The uric acid in the urine is not increased, (h) The lym- 
phatic hyperplasia may also involve the lymphatic structures in the 
tonsils, circumvallate glands of the tongue, the muscles, mammae, eye- 
lids, tibia, thyroid, or thymus; secondary deposits may be noted in 
the lungs, liver, heart, pleura, and more rarely in the brain, genitalia, 
and pelvis. 

6. Fever. — Fever is common. Gowers and Murchison observed a 
chronic recurrent type, which was later described by Pel and Ebstein; 
the term is a misnomer, and classification of this febrile variety, as a 
separate form, is incorrect, for it has been observed in chronic malaria, 
lymphosarcoma, other malignant diseases, and in glandular and splenic 
tuberculosis which simulates Hodgkin's disease. The urine may show 
the diazo reaction with the fever. When the disease involves the inter- 
nal glands only, the fever may simulate typhoid. Winnewarter stated 
that fever occurred when the glands decreased in size under the 
administration of arsenic. Fever is rather indicative of glandular 
tuberculosis, or of intercurrent (terminal) infections. 

Course. — The clinical course is long. The glandular swelling some- 
times decreases with, or without, therapeutic measures. The exten- 
sion from the cervical to other lymphatic glands is generally gradual, 
but may occur with great suddenness, as in Trousseau's case. An 
acute form of Hodgkin's disease is not well established, although 
cases have been reported; many are sepsis, tuberculosis, or acute sar- 
comatosis. Death may occur from intercurrent diseases, but it most 
frequently results from chronic cachexia. Obstruction of the air pas- 



PSEUDOLEUKEMIA 863 

sages occurs more frequently than in leukaemia. Death may also occur 
from twisting of the pedicle of the spleen, or from hemorrhages from 
the nose, uterus, stomach, intestines, or larynx, which sometimes 
resemble purpura hemorrhagica of Werlhof. Very exceptionally, 
transition into leukaemia is observed. It is a question whether patients 
with well-developed cases ever recover, though the disease is not so 
fatal as is leukaemia. Pleural effusions, diarrhoea, dysentery, and 
vomiting from pressure of the splenic tumor, are unfavorable compli- 
cations. 

Diagnosis, Allied Affections and Differentiation. — For pseudo- 
leukaemia there are two criteria; these are (a) the lymphadenoid 
hyperplasia and chronic inflammation observed when an excised node 
is examined histologically; other kinds of cells, or other degenerations, 
excite suspicion that the disease is other than pseudoleukaemia; and 
(b) according to Pinkus, an absolute lymphocytosis, with a practically 
normal number of white blood cells. Differentiation from similar 
affections is as follows: 

1. Glandular Tuberculosis (Sternberg, Noothaft, Goldman, Kanter, 
Delafield, Crowder, Askanazy, Waetzoldt). — Hodgkin's disease may 
be complicated by, or confused with, tuberculosis; in pseudoleukaemia 
the typical structure of the tubercle is lacking, but in tuberculous aden- 
itis, there may rarely be a diffuse accumulation of large endothelioid 
cells between which lie tubercle bacilli (Ziegler); after a long course, 
caseation and giant cell formation may result; the forms of glandular 
tuberculosis are (a) Ziegler 's large cell infiltration, (b) purely hyper- 
plastic lymphoid proliferation, or (c) anatomical tubercles. Of late, the 
number of reported instances of glandular tuberculosis simulating 
Hodgkin 's disease has been increasing enormously. The author exam- 
ined 2 cases of supposed pseudoleukaemia in which tubercle bacilli 
(without anatomical tubercles) were found in numbers in the spleen 
and lymph nodes. In the neck, tuberculous adenitis is more often in 
the submaxillary than in anterior and posterior glands, in the latter 
of which pseudoleukaemia is more common. Tuberculosis is more 
frequently a local than a general adenitis, and is more often attended 
by secondary suppuration. Tiirck believes that fever and glandular 
tenderness indicate tuberculosis, and that node-like swellings of the 
lymph vessels in the mouth are symptomatic of pseudoleukaemia. 
Excision of a node or operation determines the question. 

2. Anaemia Infantum Pseudoleuksemica. — This disease was first fully 
described by von Jaksch, though earlier observed by Senator; it is 
known in Italy as anosmia splenica infettiva dei bambini; it is called 
"anaemia splenica," or " pseudopernicious anaemia of children," by 
Ehrlich. It is a profound anaemia in which the blood findings suggest 
pernicious anaemia; that is, there are normoblasts, megaloblasts, 
decrease of the red blood cells (1J to 3 million), and sometimes poiki- 
locytes, or polychromatophilia ; there is often increase of the leukocvtes, 
but they rarely number more than 50,000. It occurs in young children 
from nine to eighteen months of age; the convalescence is usually very 



864 DISEASES OF THE BLOOD 

slow, or death may result. Its symptoms are hardness and enlarge- 
ment of the spleen, swelling of the liver (less than in leukaemia and less 
than the swelling of the spleen), signs of profound anaemia and hemor- 
rhages into the skin or from the nose, mouth, stomach, or intestines. 
The status of the disease is not yet determined, because the lymphocytes 
are frequently increased in children, and leukocytosis, in general, has 
less significance than in adults. The diagnosis is especially difficult 
when it occurs in syphilitic children; syphilis, rickets, and dyspepsia, 
are common antecedents. 

3. Anaemia Splenica. — Doubt has been expressed whether it should 
be classed as an essential anaemia, liver cirrhosis, chronic splenitis, or 
as a splenic form of Hodgkin 's disease, (a) The spleen is enlarged, its 
capsule thick, its stroma increased, and the endothelium of the lymph 
sinuses sometimes proliferated. The cause is unknown ; possibly it is 
toxic, (b) There is an ancemia of the secondary, or chlorotic, type; 
the red cells average 3,500,000, the haemoglobin is even more reduced 
and the whites are decreased to 3 or 4 thousand, (c) Hemorrhages, 
particularly from the stomach, are frequent, (d) In many cases there 
is a terminal liver cirrhosis (Banti's disease), with icterus and ascites. 
(e) Its course is very chronic, covering years. In some cases there are 
profound alterations of nutrition, as stunted growth, clubbed fingers, 
or pigmentation of the skin (in 8 of Osier's 18 cases). In several cases 
Dock and Warthin found portal thrombophlebitis and hyperplasia 
of the haemolymph glands. Of Lichty's cases 5 recovered, 12 showed 
improvement, and 7 died. 

4. Lymphosarcomatosis. — This is sometimes most difficult to dif- 
ferentiate, and some clinicians, as Hoffmann, class the two diseases 
together. According to Kundrat, lymphosarcoma is largely a local 
disease, with local glandular involvement, especially of the cervical 
glands, leading to infiltration of the throat by contiguity; the disease 
may begin in the tonsils, the air-passages, the portal glands, etc. Lym- 
phosarcoma ulcerates and transgresses the gland capsule; this never 
occurs in leukaemia or in pseudoleukaemia. The glands in leukaemia 
and pseudoleukaemia may compress neighboring structures but never 
actually invade them. Unless lymphosarcoma extends beyond the 
capsule of the glands, it cannot be distinguished by physical examina- 
tion unless it lies in parts which can be easily inspected, as the mouth. 
The spleen may be enormously enlarged. According to Pinkus, the 
leukocytes are increased in pseudoleukaemia while in lymphosarcoma 
they are decreased. 

5. Other Splenic Enlargements. — The most common of these are: 
Cirrhosis of the liver, malarial spleen, sometimes carcinoma, chlorosis 
with enlarged spleen (Chvostek), chronic polycythaemic cyanosis 
(characterized by (a) enlarged spleen, (b) cyanosis, and (c) increase in 
the red cells) and finally miliary tuberculosis of the spleen, actino- 
mycosis, syphilis, rhachitis or echinococcus which are rarer forms 
(see Diseases of Spleen). 



PSEUDOLEUKEMIA 865 

6. Multiple Myeloma. — This is characterized pathologically by 
lymphoid hyperplasia of the bone marrow, occurring in the ribs and 
body-ends of the long bones chiefly, and more often in the proximal 
than in the distal bones; no metastases occur. The bones soften or 
sometimes sclerose. Clinically, it occurs in males over forty-five years 
and is characterized by severe, deep-seated pain in the body, chest, 
spine, neck, and more rarely in the extremities. Prominences in the 
bones, spontaneous fractures, especially of the sternum and ribs, and 
kyphosis, from softening of the vertebrae, may result. The growths 
may rupture externally. The x-rays may clearly define them. They 
sometimes pulsate. Severe ansemia, marked nervous disturbances, 
as neuralgia, motor and sensory paralyses, which usually develop late 
and involve the opticus, hypoglossus, facialis, cord (paraplegia dolo- 
rosa), and sciatic nerve; fever and the Bence-J ones' albumosuria are 
observed. The ansemic blood findings show no increase of the white 
cells. To call this disease a myelogenic form of pseudoleukemia, or 
myelogadenia, there must, according to Pinkus, be a lymphocytosis. 

7. Other Affections. — Syphilis of the lymphatic glands (lymphoma 
gummosa); symmetrical lymphoma of the lachrymal and salivary 
glands of Mikulicz, which are simple lymphoma reacting to arsenic, 
and resembling pseudoleukemia ; and secondary carcinoma, or sar- 
coma must be differentiated. Difficulties of diagnosis are met when 
the enlarged glands in internal parts produce topical symptoms, thus 
simulating hypertrophic cirrhosis, when it begins in the spleen. 

Treatment. — 1. Local Applications. — These are useless, excepting 
the x-rays; William A. Pusey states that two of his cases, seen by the 
author five years ago, wholly recovered. In some cases the rays have 
no influence on the spleen and glands, and in others the cachexia 
increases, though there may be improvement in the local findings. 
Inunctions of green soap, given once or twice daily, are sometimes 
beneficial, and in one instance the author saw marked temporary 
benefit. 

2. Drugs. — Arsenic is most efficacious (v. Pernicious Anaemia 
for details); it acts on the glands more than on the spleen. Some 
clinicians believe that the fever which it sometimes produces, reduces 
the adenopathy. Winnewarter and Billroth recommended its paren- 
chymatous injection into the glands, but the results are not very encour- 
aging. Iodides are seemingly injurious. Berberin hydrochlorate gr. 
xv increases the appetite and contracts the spleen (Litten). For 
hemorrhages Litten uses a decoction of quercus cortex, which rather 
disturbs digestion ; equal parts of formalin and rectified spirits locally 
(which may irritate a delicate skin), and guacamphol gr. iij to iv once 
or twice daily may be given. 

3. Surgical Treatment. — Extirpation of the glands is seldom bene- 
ficial. The removal of the spleen is attended by constantly decreasing 
mortality. In 1900, Bessel-Hagen collected 360 operations for various 
indications ; the average mortality was 38 per cent, (for splenomegaly, 
61 per cent, before 1891, and since then, 13 per cent.). In 1901. Harris 

55 



866 DISEASES OF THE BLOOD 

and Herzog reported 2 operated cases, and collected 17 others, the 
mortality being 20 per cent. In Lichty's 25 cases, 8 were operated on 
with a 37 per cent, mortality. Scott has added 6 cases, of which 33 
per cent. died. 

Carstens, in November, 1905, collected 739 cases of splenectomy 
for various diseases of the spleen; 72 per cent, recovered. 



THE HEMORRHAGIC DISEASES. 

The hemorrhagic diseases may be classified roughly as follows : 



(A). Acquired types. 



1. Purpura. 

2. Scurvy. 



(B). Congenital (hereditary) type. 3. Haemophilia. 



(F). PURPURA. 

Purpura includes a number of affections, more or less similar in 
kind and differing chiefly in degree, some of which are symptomatic, 
though others are independent but obscure affections. 

Symptomatic purpura is observed as a symptom in: — (a) Various 
infections, as endocarditis, scarlatina, measles, smallpox, rheumatism, 
typhus, sepsis (strepto-, pneumo- and staphylococcus, and bac. pyo- 
cyaneus and coli), anthrax, cholera, yellow fever, plague, syphilis, or 
tuberculosis, (b) Toxic conditions, as nephritis, cholsemia, snake- 
bites, and drug-poisoning (from copaiba, ergot, belladonna, quinine, 
mercury, iodides, bromides, or arsenic), (c) Cachexia?; old age, mal- 
nutrition, carcinoma, sarcoma, leukaemia, pseudoleukemia, or per- 
nicious anaemia, (d) Nervous states; cerebrospinal lesions, as tabes, 
myelitis; neuroses (bloody stigmata of hysteria); neuralgias, or vaso- 
motor fluxions, (e) Mechanical conditions, as trauma, embolism, 
or stasis. 

Purpura simplex (Zeller, 1684), is purpura in which the cutaneous 
hemorrhages are the chief symptom. Its etiology is obscure. It 
develops most often in middle-aged males. As in the other forms, 
whose description follows, there is no constant nor characteristic 
pathology, though vessel alteration (thickening, hyaline, and fatty 
degeneration), thrombosis, hemorrhage, and pigmentation sometimes 
occur. In the blood itself no change is observed other than its tardy 
coagulation; this requires 10 to 30 minutes, instead of 3 to 5, which 
is the normal time. The eruption begins as small red spots, which 
gradually become green and black; they occur largely on the extensor 
surfaces of the limbs, and more often on the legs than on the arms or 



PURPURA 867 

trunk. They do not fade upon pressure. The initial eruption may 
be macular, papular, or urticarious (purpura maculosa, papulosa, 
or urticans), but soon becomes blood-tinged. Constitutional symptoms 
are usually absent; there may be slight fever, gastric disorder, or 
diarrhoea (Graves). The usual duration is 1 to 2 weeks, the prognosis 
is good, and the treatment hygienic rather than medicinal. Relapses 
are common. 

Purpura (or peliosis) rheumatica is a form described by Schoenlein, 
and still generally listed by itself because of the articular symptoms. 
As] joint symptoms also occur in Werlhof's disease (v.i.), scurvy and 
haemophilia, its separate classification is somewhat arbitrary. Most 
cases develop in males between fifteen and thirty years of age. It has 
no relation to rheumatism proper, being a pseudorheumatism. Its 
pathology is obscure. 

Symptoms. — (a) As prodromes, indisposition, low fever, muscular 
pains, colic, and particularly sore throat, may be noted. The developed 
disease is manifested chiefly by various forms of purpura, and by symp- 
toms in the joints; (6) the purpura may occur before, with, or after 
the joint-symptoms. It occurs as simple hemorrhages of the skin, 
which vary from red to green-black according to their age, or as urti- 
caria, erythema, pemphigus, or oedema, which become stained with 
blood; the legs are most often involved, largely on the extensor sur- 
faces, (c) Articular symptoms are most common in the knees and 
ankles, being less frequent in the elbows, and rare in other joints; 
there may be only stiffness and pain, or there may be actual swelling; 
if the joints are first involved, their symptoms frequently abate with 
the appearance of the purpura, and may- last but 5 to 10 days, (d) 
Other symptoms are inconstant, as fever, which may rise to 102° or 103°, 
splenic tumor, albuminuria, or nephritis. The author once had 3 cases 
at one time in the Cook County Hospital, in which there was severe 
sloughing of the tonsils. Osier (1904) described 29 cases in which 
visceral lesions occurred with purpuric, urticarious, and erythematous 
symptoms; they occurred chiefly in children, and relapses were fre- 
quent; (i) digestive complications occurred in 25 cases; vomiting in 
15; colic in 8 (resembling renal stone or appendicitis); blood in the 
stools in 8, and diarrhoea in 15; (ii) acute nephritis occurred 14 times, 
and 5 cases died of uraemia; (iii) arthritis occurred in 17 cases; (iv) 
swelling of the fauces, oedema of the larynx, aphasia, transient hemi- 
plegia and least often endocarditis, may occur. 

The diagnosis chiefly concerns affections characterized by hemor- 
rhages of the skin, articular symptoms and perhaps temperature. 
Acute leukaemia, septicopyaemia and endocarditis must be excluded. 
Genuine rheumatic polyarthritis is usually differentiated with ease by 
the earlier migrating, inflammatory joint involvement, the tempera- 
ture, sweating, characteristic cardiac complications, and the later, 
rather accidental and wholly secondary occurrence of the purpura. 

The prognosis is generally good, though relapses are common and 
sometimes periodical. Its course is rarely longer than a week or two. 



868 DISEASES OF THE BLOOD 

Treatment is hygienic and symptomatic. The joint-symptoms yield 
somewhat to acetanilide and salicylates, though the latter exert no 
specific influence. 

Purpura hemorrhagica (Morbus maculosus Werlhofii, Werlhof , 1775) 
closely resembles the sub-types already described, but differs from 
them in that not only are the skin and joints the seat of hemorrhage, 
but also the mucous membranes, serous membranes, and perhaps the 
viscera. 

Etiology. — Of this little is known ; staphylo-, strepto- and pneumo- 
cocci, Bacillus pyocyaneus and coli,and one like Friedlander 's pneumo- 
bacillus have been found. It occurs oftener in young weakly women 
than in robust adults. Exposure to cold or dampness, and malnu- 
trition seem to be predisposing causes. It usually develops as an 
apparently primary affection, but it may occur in some of the conditions 
listed under symptomatic purpura. 

Symptoms. — Perhaps after inconstant and variable prodromes, as 
fever, vomiting, or vertigo (a) hemorrhages appear on the extremities; 
the face is not often involved; they occur as spontaneous petechias, 
blood-stained bullae, or vibices, or may result from slight trauma, as 
by pinching the skin, (b) The mucous membranes bleed to a varying 
degree; the nose and mouth bleed most often; less frequently there 
is haemoptysis, haematemesis, enterorrhagia, hematuria, and metror- 
rhagia, in various combinations, sequences, and degrees. The con- 
junctivae may be blood-stained. The writer saw one rapidly fatal case 
in which there was hemorrhage from the middle ear. (c) The serous 
membranes, and the joints, particularly the knees, ankles, and elbows, 
are often implicated. Ecchymoses in the endo- and pericardium, 
pleura, peritoneum, and meninges are common findings at autopsy 
(d) Other hemorrhages are much less common, as retinal hemorrhages 
hemorrhage into the brain, cord, or testis. The connective tissues, 
fasciae and bones are practically exempt. 

There may be general symptoms and complications. As to the blood, 
there is delayed coagulation and some anaemia, but the red cells and 
haemoglobin are rarely much reduced; some nucleated red cells may 
be found, as well as leukocytosis, reduction in the blood plates, and 
some methaemoglobinaemia. Fever is inconstant and atypical. The 
pulse rate may be raised; palpitation, delirium, vertigo, albuminuria, 
hepatic enlargement, splenic tumor, subicterus, and nephritis are 
occasional symptoms. In J. S. Cutler's case, there was extensive intes- 
tinal ulceration ; perforation has been also reported, 

Diagnosis. — Most errors in diagnosis result from confusion with 
those purpura cases which are symptomatic of sepsis, hemorrhagic 
exanthemata, or blood affections. The difficulties in diagnosis are 
often great; in an anaemic old man, who suddenly vomited blood and 
passed bloody urine, the diagnosis of purpura was made; the autopsy 
revealed a round ulcer of the stomach, and a papilloma of the bladder. 
Scurvy is distinguished by its gingivitis and muscular hemorrhages, 
and haemophilia by reason of its hereditary facts. Henoch's^ purpura 



HEMORRHAGIC DISEASES OF THE NEW-BORN 869 

is a type which occurs chiefly in children, and is characterized (a) by 
cutaneous lesions, which resemble erythema nodosum rather than 
purpura; (b) by hemorrhages of the mucous membranes; (c) by 
gastro-intestinal crises of vomiting, diarrhoea, and abdominal pain; 
(d) by pains in the joints, and (e) by frequent relapses, often over a 
number of years (v. s. Osier 's group). 

Prognosis. — The prognosis is uncertain. According to Gross, 50 
per cent. die. Unfavorable symptoms are sudden onset, high tempera- 
ture, and extensive hemorrhages. Purpura fulminans, of which Styler 
(1906) collected only 14 cases, may be fatal in 24 to 48 hours. Recur- 
rence is not uncommon. 

Treatment. — This has advanced but little beyond Werlhof *s therapy 
of giving dilute sulphuric acid tt£x, and quinine gr. v after meals. 
Everything of a supportive nature, as sufficient nourishment, rest in 
bed, iron and arsenic, are helpful. The hemorrhages are arrested 
with difficulty, and the author doubts the value of drugs in their control. 
Turpentine and ergot may be given (as in hsemoptysis q.v.). Adren- 
alin solution to the nose and mouth, gelatin by mouth (see Next 
Section), and especially calcium chloride gr. v, t. i. d., to increase the 
coagulability of the blood, are indicated. 



(G). HEMORRHAGIC DISEASES OF THE NEW-BORN. 

Syphilis hemorrhagica neonatorum appears soon after birth. In 
some instances the syphilitic child may be born with hemorrhages in 
the skin, mucosae, internal organs, and from the navel. Occasionally 
deep jaundice develops. The cause is probably vascular disease; 
Mracek found endarteritis, especially of the capillaries, in 14 per cent, 
of 19 cases. In other cases an added sepsis is apparently causative. 

Winckel's disease, epidemic hemoglobinuria, is (a) an affection of 
the new-born of unknown causation; (b) it appears epidemically in 
hospitals; (c) it develops in the first four days of life; (d) it is char- 
acterized clinically by fever, gastro-intestinal symptoms, icterus, 
dyspnoea, cyanosis, albuminuria, methsemoglobinuria and large mor- 
tality, and (e) pathologically by internal hemorrhages, fatty degenera- 
tion, and splenic tumor. 

Morbus maculosus neonatorum is no clearer etiologically than 
Werlhof 's disease in adults ; some cases come under congenital syphilis ; 
others with fever, jaundice, and epidemic occurrence under infection 
(pyogenic cocci, pneumococci, a bacillus like Friedlander's, pyocyaneus, 
and colon bacillus), and still others seem embolic, thrombi forming in 
the auricles when the heart is weak (Landau). Injuries to the head, 
causing hemorrhages in the fourth ventricle and cerebral peduncles, 
and other vasomotor disturbances (von Preuschen, and Pomarski) 
are questionable causes. It occurs once in 500 to 700 births. 

Symptoms. — In the first week of life, hemorrhages occur from the 
navel and mucous membranes; in Townsend's 50 cases thev occurred 



870 DISEASES OF THE BLOOD 

in the following frequency: from the bowel (melama), 40 per cent.; 
navel, 36 per cent.; mouth, 28 per cent.; stomach, 28 per cent., and 
nose, 24 per cent. Death occurs within a week in 62 per cent. Dusser, 
in 78 cases, found the mortality was 55 per cent. 

Treatment. — Iron, ergot, and adrenalin are useless. Diffuse stimu- 
lants should be given when there is a weak, rapid pulse. Injections of 
gelatin are dangerous, for it possibly contains some ptomaine, and its 
local use and administration by mouth are safer. 



(H). SCURVY. 

Definition. — A general disease, more often endemic than sporadic, 
caused by neglect of hygienic conditions, and characterized by gingi- 
vitis, hemorrhages, inflammations, cachexia and chronicity of course. 

Etiology. — It was first observed in the Crusades, and was described 
most fully by Vasco de Gama; in his voyage around the Cape in 1498, 
33 per cent, of his sailors were stricken with scurvy. It has developed, 
not only among sailors, but among prisoners, Canadian lumbermen, 
Pennsylvania miners, and among the workers on the Chicago Drainage 
Canal, where in 1893-95, the author saw 100 cases. Insufficient, monot- 
onous, possibly spoiled, food causes the majority of cases, sometimes, 
in conjunction with lack of fresh air, impure water, damp quarters, 
and over-exertion; a lack of fresh meat, vegetables (potassium salts, 
malic and citric acids), and fats predispose to scorbutus, though the 
lack of no single group is solely responsible. The Chicago Drainage 
Canal cases were all Poles, and lived on coffee, bread, and preserved 
and fresh meat. It develops principally in middle-aged males of the 
poorer classes. The disease is becoming less frequent. In 1780, 
Admiral Gleary had 2,400 cases in the English fleet, and in 1849, there 
were 260,444 cases in Russia, and 60,958 deaths. It is still widely 
endemic in Russia, where it is regarded as an infection. 

Symptoms. — Scorbutus begins slowly, and progresses insidiously; 
its earliest symptom is (1) ancemia (cachexia scorbutica). The skin is 
scaly, pale, lustreless, and may become pigmented. The mucous mem- 
branes are rather livid, and the expression is apathetic. The blood 
findings are not characteristic; coagulation is slow, the red cells and 
haemoglobin are proportionately reduced, and leukocytosis is absent, 
except with intercurrent inflammation or severe hemorrhage. Emacia- 
tion, mental depression, muscular weakness, fatigue, anorexia, reduc- 
tion of HC1 in the gastric juice, intestinal fermentation, constipation, 
palpitation, weakness with irregularity of the heart 's action, a systolic 
functional murmur, and oedema about the ankles accompany the 
anaemia. Splenic enlargement, albuminuria, peptonuria and oliguria 
are common. 

2. Gingivitis begins with turgescence of the gums, which is due to a 
serohemorrhagic infiltration, usually noticed first about the canine 
teeth; the gums are spongy, painful, particularly on eating, bleed 



SCURVY 871 

readily, and may become so swollen as to hide the teeth. Gingivitis 
is absent when there are no teeth or roots. The breath is extremely 
foetid. In severe cases the gums necrose, and bleed profusely; deep 
ulcers, on healing, leave cicatrices; the teeth may loosen and fall out, 
the salivary and cervical lymph glands and tongue may swell. Necro- 
sis of the jaw is uncommon. 

3. Hemorrhages may occur (a) in the skin, especially on the extensor 
surfaces of the legs; small hemorrhages often occur, first about the 
hair follicles; they are at first small petechise, but later become larger 
and stretch the skin. In less frequent instances, the first eruption may 
resemble acne, herpes, or pemphigus, hemorrhages appearing later in 
these exanthems. The trunk is less frequently involved, and the face 
is usually exempt. As the hemorrhages increase, the legs are diffusely 
mottled with red, green, and black, and are swollen, tense and somewhat 
warmer than normal. Similar stains may be noted running upward 
in streaks along the lymph vessels. Some of these changes are due to 
(b) muscular hemorrhages (scorbutic sclerosis). They occur mostly in 
the calf and thigh, less in the buttocks, or abdominal wall. The legs 
are large, extremely hard, blood-stained, and later pigmented. As the 
disease regresses the muscles usually recover their function, but in 
some instances ulceration (scorbutic ulcers), suppuration, muscular 
cicatrization, or pressure atrophy and shortening of the tendons may 
leave permanent deformity and contractures, (c) Mucous membrane 
hemorrhages are less common than in purpura or haemophilia, though 
epistaxis is fairly frequent. In some cases hemorrhages occur in the 
conjunctiva, air passages, and stomach, but in more cases in the bowels, 
perhaps with intestinal ulceration, id) Of serous membrane hemor- 
rhages, articular hemorrhage (hsemarthrosis) is the most frequent. 
Next in order of frequency are those in the pleura, pericardium, 
peritoneum and meninges. They are usually sudden in onset, extreme 
in degree, and unfavorable in outcome, (e) Parenchymatous hemor- 
rhages are least common, as in the eye-tissues, brain, and other viscera. 
Subperiosteal and epiphyseal hemorrhages are rare, unless Barlow's 
disease is included (see Next Section). Scorbutic ulcers in soft tissues 
may reach the bone, causing necrosis. 

4. Scorbutics are subject to various inflammations, (a) Painful 
joint swellings are the most frequent, and occurred in 35 per cent, of 
the author's cases, and chiefly in the knees; they may be serous or 
hemorrhagic, or in severe cases the cartilages or bones may become 
eroded and ulcerated; sometimes suppuration intervenes; deformity 
and ankylosis are possible sequences. (6) Hemorrhagic pericarditis 
and pleuritis are very dangerous, (c) Onychia, paronychia, choroid- 
itis, and panophthalmitis are occasional incidents. Fever is uncom- 
mon, except from extreme inanition or terminal infection. 

Course and Prognosis. — The onset is insidious, the course chronic, 
and convalescence protracted. Most cases recover, after which recur- 
rence is not frequent. Death may occur (a) from cachexia, and the 
autopsy then shows fatty degeneration of the heart, liver, and blood- 



872 DISEASES OF THE BLOOD 

vessels; (6) from profuse hemorrhages, into the pleura, pericardium, 
gastro-intestinal tract, or rarely into the brain, or meninges; (c) from 
infections, as dysentery, pleurisy, pneumonia, or septicopyemia, prob- 
ably of the terminal type, and promoted by the reduced physiological 
resistance. 

Diagnosis.— The diagnosis is usually made without difficulty from 
(a) the anaemia or cachexia, (b) gingivitis, (c) tendency to hemorrhage, 
and (d) inflammation, (e) the chronic course, and (/) the temporary 
nature of the condition (as contrasted with the most permanent ten- 
dency to hemorrhage in haemophilia). 

Treatment. — (a) Hygienic; avoidance of " cured" or smoked foods 
is both prophylactic and curative. In Nansen J s polar expedition, which 
lasted three years, not one case of scurvy developed. His meats were 
cooked, and plenty of cooked and raw fruits and vegetables were used. 
Berries, sauerkraut, potatoes, radishes, cress, apples, oranges, and 
lemons are especially valuable. A monotonous dietary is particularly 
to be avoided, (b) The anosmia (q.v.) should be treated by strychnine, 
quinine, iron, and arsenic. Yeast gij two or three times daily, is 
recommended, (c) The gingivitis is treated by occasional local applica- 
tions of silver nitrate (10 per cent.). Cocaine may be painted on the 
gums before meals, so that the patient may be able to eat, but great 
care in its use must be taken, lest the habit be contracted, or toxic 
symptoms develop, (d) Symptomatic treatment; hemorrhage is bene- 
fited by rest only. Stimulation is required in intercurrent pericarditis, 
and pleuritis. Drastic cathartics are to be avoided. Complicating 
arthritis necessitates rest and the application of cold, but rarely aspira- 
tion or drainage. 



(I). INFANTILE SCURVY— BARLOW'S DISEASE. 

Moller (1852-62) described the affection as acute rhachitis, and 
Ingerslev (1871), Jalland (1873), Cheadle and Gee (1878), but par- 
ticularly Barlow (1883), described a cachexia with hemorrhages, 
which occurred in the very young. De Bruin observed 61 cases in 
Holland in 1893. In 1898, 379 cases were collected in the United 
States. 

Etiology. — Unlike scurvy in adults, the hygienic conditions are good 
in 80 per cent, of cases, and it occurs largely in the better classes. 
(a) The obvious cause is feeding with malted, condensed or cooked 
milk or baby foods; these foods lack some unknown substance which 
is essential to health. The malady is very rare in breast-fed infants. 
In 713 cases (S. Weiss, 1905) only 20 or 2.5 per cent, occurred in infants 
at the breast, (b) Ninety per cent, of cases occur between the sixth 
and twelfth month (Heubner's and Neumann's 94 cases). 

Symptoms. — These are not always typical; there may be anaemia 
("cachexia") without hemorrhages, or hemorrhages without ansemia, 
though in typical cases they occur together. 



HEMOPHILIA 873 

1. Subperiosteal hemorrhage is the leading symptom. There may 
be at first some vague symmetrical swelling over the epiphyses, which 
later becomes more obvious, though no real oedema is noted. There 
is pain and tenderness usually in the thighs or legs, which are drawn 
up, flexed or everted, immobile and semiparalytic (pseudoparalysis). 
At autopsy, the anatomical findings are subperiosteal hemorrhages ; 
a colloid and fibrillar alteration in the marrow of the diaphyses; 
arrest of ossification; decrease of the osteoblasts; rarefaction of the 
bone, sometimes leading to fractures (spontaneous or after slight 
trauma), or to epiphyseolysis (usually at either end of the femur or 
the upper end of the tibia); the joints are normal. Seventy per cent, 
of the lesions is in the thigh, 24 per cent, in the leg, and 6 per cent, 
in the orbit; the arms, ribs, spine, skull, sternum, and scapula, are not 
often involved. Rib involvement results in depression of the sternum. 

2. The cachexia is evidenced by the ansemia (usually moderate and 
sometimes attended by slight lymphocytosis), sallow skin, asthenia, 
anorexia, constipation, irregular temperature (in 66 per cent.) or sub- 
normal registration and the almost invariable severe sweats. 

3. Gingivitis is noticed when the teeth have already erupted or 
are about to erupt. In 73 cases (Heubner and Neumann), the gums 
were normal in but 15 per cent. 

4. Other symptoms embrace hemorrhages in the skin in 15 per 
cent., from the kidneys in 9 per cent, (hemorrhagic nephritis), and 
rarely in the conjunctivae, muscles, stomach, bowels or meninges. The 
spleen is rarely swollen. 

Diagnosis. — Diagnosis is not difficult, after one typical case has 
been seen; it is based upon the etiology, subperiosteal hemorrhages, 
gingivitis and anaemia (cachexia). Confusion with genuine paralysis 
is unnecessary, for the immobility is voluntary to escape the pain of 
movement. Syphilitic bone disease (syphilitic pseudoparalysis or 
Parrot's disease) is rather similar as to the crepitus, epiphyseolysis 
and pain, but other syphilitic stigmata or scorbutic symptoms are 
generally present. 

Prognosis and Treatment. — Proper treatment secures marked and 
immediate improvement in the great majority of cases. Death is 
uncommon; in unfavorable cases, it occurs in the third or fourth 
month of the disease. 

The diet consists of raw cow's milk, potato puree, and beef juice 
(not broth or extracts); orange juice, apple sauce, pears, cooked 
berries and spinach are most beneficial. Treatment by drugs is gen- 
erally superfluous. 

(J). HEMOPHILIA. 

Definition.— A congenital and hereditary affection, characterized by 
deficient coagulability of the blood, and a consequent tendency to 
various profuse hemorrhages, which are spontaneous or traumatic, 
and are most difficult to arrest. 



874 DISEASES OF THE BLOOD 

Etiology. — Its real cause is unknown, and the few pathological 
changes described in the blood and the bloodvessels are insufficient 
factors. Sahli believes that there is an hereditary deficiency in the 
fibrin -forming substances (thrornbokinase). (a) Heredity is the only 
clear etiological fact, which Fordyce noted in 1784; as Grandidier 
remarks, haemophilia is "the most hereditary of all hereditary diseases." 
Osier quotes Brown as observing haemophilia through seven generations. 
Sometimes a generation may be exempt, (b) Broadly speaking, the 
males of the "bleeder families" are the "bleeders," and the females 
transmit the disease to their male offspring without manifesting the 
disease themselves. In 200 families of "bleeders," Grandidier found 
609 cases in males, and 48 in females (8 per cent.); Stahel in 1,880 
families found only 24 cases in males. In the Mampel family, first 
reported by von Chelius in 1827, Lossen (1905) found 212 members 
of which 111 were males; of these exactly one-third were bleeders, 
and 48.7 per cent, of the male bleeders died of hemorrhage; none of 
the females were bleeders and all transmission of the disease occurred 
through the women, (c) The disease occurs most frequently in Ger- 
many, England, North America and France. Consanguinity and family 
tendencies (gout, rheumatism, or tuberculosis), have been suggested 
as causes. "Bleeders" are generally healthy individuals with soft, 
delicate skins. 

Symptoms. — In 75 per cent, of cases, hemorrhages develop in the first 
two years of life; rarely do they first appear after puberty or in the 
third decade, though isolated observations are recorded of persons 
having their first hemorrhages after the seventieth year. The hemor- 
rhages are spontaneous or traumatic; they most often occur as capil- 
lary oozing from a mucous surface; deep interstitial bleeding is most 
unusual. They are copious and hard to still. Epistaxis is the most 
common (50 per cent.); hemorrhages from the gums (12 per cent.), 
intestine (12 per cent.), lungs, kidneys and stomach (each 6 per cent.) 
are] next in frequency. Uterine hemorrhage and arthropathies are 
not infrequent. According to Konig, the joint findings are (a) an 
haemarthros, with pain, swelling and fluctuation; (b) then panarthritis, 
whose gross pathology resembles tuberculous arthritis, with flexion of 
the joint; (c) regression, or ankylosis and deformity, which rather 
resembles arthritis deformans. The knees and elbows are most often 
affected. Subcutaneous hemorrhages may occur. The first bleed- 
ing may occur from the navel, or may result from vaccination, 
extraction of teeth, circumcision, from a trifling prick or cut, from 
delivery, or from rupture of the hymen on the wedding night. In 
various attacks, one part after another may bleed or the hemophilic 
disposition may be confined to one part, as a kidney (renal haemophilia). 
Haemophilia differs from purpura, in that the bleeding seldom occurs 
into a serous membrane (excepting the joints), or into the viscera. 
The amount of blood lost may be enormous, and in one case amounted 
to 24 pounds in eleven days. The coagulation test of the blood may 



HAEMOPHILIA 875 

show that coagulation is delayed to thirty or forty-five minutes (Wright) ; 
the clot, when formed, is porous. 

Of general symptoms, there are few except changes in the joints 
(like those in subacute rheumatism), a neuropathic tendency (neuroses 
and neuralgia, particularly of the fifth nerve), and anaemia (though 
hemophilics tolerate loss of blood better than other individuals, show 
it less, and recover from it more readily). 

Diagnosis. — The diagnosis may be for a time uncertain, when 
hemorrhage develops after an operation, or occurs from one organ only, 
as the kidney. The family history clearly stamps the affection, and 
readily differentiates it from scurvy, purpura and hemorrhages in the 
new-born. 

Prognosis. — The prognosis is grave. Any hemorrhage may prove 
fatal. Sixty per cent, of cases die before the eighth year, and only 11 
per cent, reach the twenty-second year; if middle life is reached, the 
danger gradually lessens. It is more favorable in girls, despite the 
apparent menstrual dangers. De Bons (1905) found 69 excessive 
hemorrhages among 150 deliveries in hemophilic women; he believes 
pregnancy has a rather favorable effect on the disease. De Lee has 
reported premature detachment of the placenta in hemophilia. The 
rudimentary or local forms are more favorable than general hemophilia. 

Treatment. — 1. Prophylaxis. — Grandidier lays down the following 
rules : (a) women, with an hemophilic family tendency, whether they 
are "bleeders" or not, should not marry, (b) Men, if not " bleeders" 
themselves, may marry, (c) Men should not marry when their family 
history indicates that male "bleeders" have begotten hemophilic 
children. It is obvious that in hemophilic families, general measures 
to elevate the physiological resistance, and avoidance of trauma or 
any but life-saving operations, are indicated. Vaccination is rarely 
contra-indicated. 

2. Control of Actual Hemorrhage. — This is almost impossible, (a) 
Wounds should be cauterized or enlarged, as Fordyce discovered that 
in hemophilics large bleed less than small wounds. Other surgical 
hemostatic measures need not be further considered. The Esmarch 
constrictor controls some hemorrhages of the extremities. (6) Styptics, 
as MonselFs solution, or tannic preparations, are useless, (c) Adren- 
alin, locally and internally, has no apparent affect, (d) Calcium 
chloride is somewhat more beneficial, grs. iij to v t.i.d. should be 
given ; it should be given intermittently, because protracted adminis- 
tration decreases the coagulability of the blood, (e) Gelatin may be 
given by mouth or in unusually severe hemorrhages by sub-cutaneous 
infusion (v. Hemorrhages of the New-born). (/) Saline cathartics 
are sometimes apparently efficacious, possibly by diverting blood from 
the seat of hemorrhage, (g) Very acute anemia necessitates injection 
of salines under the skin; when the hemorrhage is over, regeneration 
of the blood is remarkably rapid, (h) Joint involvement is treated 
by rest, immobilization, and rarely aspiration. 



SECTION VII, 



DISEASES OF THE DUCTLESS GLANDS. 



(A). DISEASES OF THE SUPRABENAL GLANDS. 

ADDISON'S DISEASE; OTHER AFFECTIONS OF THE SUPRA- 
RENAL GLANDS. 

Definition. — A disease characterized (a) pathologically by lesions 
(usually tuberculous) in the adrenal glands or by degenerative changes 
in the adjacent abdominal sympathetic ganglia, and (6) clinically by 
langor, muscular and mental adynamia, digestive disorders, pigmen- 
tation of the skin and a fatal issue. 

Etiology. — 1. Suprarenal disease was first associated pathologically 
with melanoderma by Addison, in 1855. By far the most common 
lesion is (a) chronic fibrocaseous tuberculosis of the adrenal glands; 
the tubercles of the adrenal glands are usually bilateral, destroy most 
of the suprarenal structure, and frequently involve the semilunar ganglia 
and solar plexus by their attendant formation of connective tissue; in 
rare cases only is the adrenal tuberculosis primary, though cases were 
recorded by Symes and Fisher; there is usually a primary focus in the 
lungs (in over 50 per cent.), in the genito-urinary, alimentary or glandu- 
lar system. (6) Less common are tumors, simple atrophy, fibrous 
induration (usually tuberculous), cirrhosis (26 cases recorded), gumma, 
amyloid degeneration, acute inflammation (as by contiguity from peri- 
nephric abscess), acute hemorrhage, embolism, echinococcus, traumatic 
adenoma, or other very rare lesions. In what way suprarenal lesions 
produce Addison's melasma suprarenale is still a disputed question, for 
our knowledge of adrenal physiology is incomplete. It seems (i) that the 
glands contain a substance (sphygmogenin) which maintains vascular 

S77 



878 DISEASES OF THE DUCTLESS GLANDS 

tonus, and stimulates the vasomotor centres and nerves, the vagus, 
and respiration; when secreted in excess, as in hypernephroma, the 
blood tension may be much elevated (Fraenkel, Neusser, Kolisko) 
and this may induce cerebral hemorrhage; (ii) the glands apparently 
elaborate a substance which is necessary to life ; this internal secretion 
probably renders less toxic some substances produced by other tissues, 
e.g., the "fatigue stuffs" of muscle metabolism. Chemically, sphyg- 
mogenin, pyrokatechin, neurin and lecithin have been found. Able 
holds that the active glandular substance is epinephrin. 

There are, however, cases of Addison's disease, in which the adrenals 
are normal. Lewin's statistics from 500 cases are as follows: in 
typical cases, the adrenals are diseased in 88 per cent, and apparently 
sound in 12 per cent.; on the other hand, disease of the adrenals is 
attended by pigmentation of the skin in 72 per cent., and unattended 
by it in 28 per cent. There is no wholly satisfactory explanation for 
such cases. Perhaps compensatory hypertrophy or accessory glands 
may prevent symptoms in some cases of adrenal disease. 

2. The adjacent sympathetic structures — the solar plexus and semi- 
lunar ganglia, — may be involved directly, or indirectly as by fibrous 
changes in the adrenals, and pressure from contiguous aneurysm or 
lymphomata. Pigmentary atrophy, hyaline degeneration and round 
cell infiltration of their vessels, and degeneration extending upward 
to the cord, or downward along the nerve fibers have been described. 
Some writers explain Addison's disease as a disease of the sympathetic 
system, though others endeavor to reconcile conflicting facts by assum- 
ing that there is decreased adrenal activity and also sympathetic 
disturbance. 

3. Minor etiological factors are (a) age; most cases occur between 
the fifteenth and fortieth years; the youngest patient recorded was a 
congenital case, and the oldest one was eighty years; (b) sex; 66 per 
cent, occurs in males; (c) social status; 90 per cent, is found in the 
laboring classes. 

Symptoms. — 1. Marked physical and mental adynamia is usually 
the initial symptom and persists, with increase after possible remis- 
sions, from onset to death. The insidious langor, weakness, apathy, 
lack of initiative and muscular relaxation contrast sharply with the 
healthy appearance of the patient, at least in the early stages. These 
symptoms are probably toxsemic, partly from reduced internal secre- 
tion and partly from the tuberculous lesion. Obstinate early in- 
somnia and headache, and somewhat later attacks of vertigo, tinnitus, 
spots before the eyes and syncope are frequent. The intellectual 
functions are somewhat weakened, neuralgias occur in the epigastrium, 
intercostal spaces, back and extremities, periodic attacks of irritability 
are frequent, and the deep reflexes are usually somewhat reduced. 

2. Digestive symptoms generally appear next. The tongue is some- 
what coated and moist; there are anorexia, thirst, a sense of abdominal 
fulness or pressure, eructations, and sensitiveness over the abdomen. 
Paroxysmal pains in the epigastrium or back radiate widely, especially 



ADDISON'S DISEASE 879 

into the chest; they resemble tabetic crises and are most severe. 
Vomiting is the most distressing, ominous, and intractable alimentary 
symptom; it may follow eating or occur independently of it. Though 
at first intermittent, it later hastens the fatal issue. Early constipation 
gives way to terminal diarrhoea. 

3. Pigmentation (melanoderma, bronzed skin, melasma suprarenale) 
develops after the adynamia and alimentary disturbance. Its cause is 
obscure; Neusser refers it to involvement of the sympathetic nerves 
or ganglia. It is found in the deep layers of the rete Malpighii, to 
which it is apparently brought from the blood by leukocytes. At first 
the skin has a dirty, yellow-gray color, and small areas appear which 
gradually fuse, and then slowly become darker and more diffuse; 
extended pigmentation may occur with focal areas of deeper dis- 
coloration. Pigmentation develops particularly (a) where it is nor- 
mally deepest, as about the nipples, anus and genitalia; (b) where 
pressure or friction is greatest, as over folds of the skin, over the 
clavicle, spine, ischia, scapulae or waist (from belts or corsets); (c) 
where there is exposure to the sun, as in the face, neck or arms; (d) 
where accidental irritation occurs, as by blistering, eczema or parasitic 
affections. The soles of the feet, palms of the hands, nail-beds and 
hair are seldom stained. Previous scars may or may not be stained; 
sometimes they are surrounded by a zone of deeper discoloration. 
The skin is dry, is sometimes bathed with profuse perspiration and 
may have a fish-like odor. Scattered spots of pigment may atrophy 
(vitiligo) and impart to it a strange appearance. The mucous mem- 
brane of the lips, gums, cheek and palate also show pigmentation, but 
usually later than the skin. The spots and horizontal ink-like stains 
on the cheek where the teeth touch it are particularly of diagnostic 
value. The conjunctivae are pearly white, and are usually said to 
be exempt, though frequently small aggregations of pigment can be 
seen on careful examination (Leva). Staining of the larynx, nymphae, 
vagina, glans penis, serous membranes and internal organs is infre- 
quent. 

4. Other findings embrace the following: (a) The heart shares in the 
general adynamia; it frequently shows brown atrophy at autopsy; its 
tones and apex are weak. Pain over the heart is frequently reflected 
from the abdomen; palpitation and dyspnoea are common, but func- 
tional murmurs are rare. The pulse is compressible and somewhat 
accelerated, seldom slow or arrhythmic. The peripheral vessels and 
abdominal aorta pulsate actively. Atheroma is common, even in young 
subjects (Kolisko). (b) Anaemia was considered characteristic by 
Addison, though Nothnagel and others have demonstrated its infre- 
quency; in a recent case, the writer observed a red-cell count of 2 
million. Increase in the red cells (polycythemia rubra), and in the 
haemoglobin results from concentration of the blood, which is due to 
vomiting and diarrhoea. The lymphocytes are somewhat increased, (c) 
The lymph nodes and Peyer's patches are sometimes hyperplastic. 
The spleen, thyroid, thymus and pineal glands are often enlarged, 



880 DISEASES OF THE DUCTLESS GLANDS 

probably vicariously. (d) Emaciation and cachexia are terminal 
rather than initial conditions. (Edema of the ankles is infrequent 
even toward the end. Characteristic metabolic changes are not found ; 
pigment in the urine is rare, acetonuria is occasional, the urea is often 
decreased and terminal albuminuria may develop, (e) The tempera- 
ture is most often normal or subnormal and a subjective chilliness is 
experienced. (/) The genital functions may decline as in any cachexia. 
(g) Tuberculosis of the lung or bowel may somewhat modify the 
symptoms. 

Diagnosis. — Diagnosis is based on (a) the prostration, psychical 
and physical; (b) digestive disorders, vomiting, diarrhoea and neural- 
gia; (c) pigmentation of the skin and oral mucosa; (d) cardiac weak- 
ness and (e) the chronic lethal course. 

As Addison's disease usually indicates the presence of tuberculosis, 
the advisability of injecting tuberculin may be considered; a reaction, 
however, may easily occur from tuberculosis in other tissues. Adrenal 
tumors may cause metastases in the brain or (like tumors of the thyroid, 
prostate and mammae), in the long bones, skull and spine. 

Clinical Course. — The cardinal symptoms described progress slowly, 
with occasional intermissions, and in nearly all cases, death results 
after a year or two; the terminal symptoms are often violent; there 
may be delirium, hallucinations, convulsions, incoercible vomiting and 
diarrhoea, irregular respiration, small pupils, occasional pseudomen- 
ingitic symptoms and finally collapse and coma. The course may 
vary: (a) acute cases may resemble typhoid, digestive disease or acute 
poisoning; (b) chronic cases sometimes last ten or thirteen years; 
(c) sudden death may occur before pigmentation develops, the supra- 
renal lesion at autopsy disclosing an anomalous type (forme fruste) of 
Addison's disease; (d) the course may be modified by pulmonary or 
intestinal tuberculosis. 

Differentiation. — Pigmentation occurs in numerous other conditions : 
(a) poisonings by silver (argyria), in which the reduced metal forms 
a gray deposit in the extracellular tissue of the skin, sweat-glands, con- 
junctiva and nail-beds; by arsenic, which seldom stains the mucosae ; 
in pellagra, which is endemic and intermittent in occurrence, with 
exacerbations in the spring and fall, is preceded by erythema, is rarely 
associated with tuberculosis, but with eosinophilia, diarrhoea, and 
voracious appetite and is exempt from mucous membrane pigmen- 
tation (Neusser). (b) Chronic icterus (which, however, stains the 
scleras and urine), cyanosis (arteriosclerosis and heart disease, also 
sometimes pigmenting the oral mucosa), various physiological pig- 
mentations, and dirt and parasites as in tramps (vagabondism), (c) 
Abdominal diseases, dyspepsia, gastric ulcer, tumor (cancer, lym- 
phomata, and Hodgkin's disease), hypertrophic cirrhosis and haemo- 
chromatosis (hepatic and pancreatic cirrhosis, diabetes and skin 
pigmentation, diabete bronze). (d) Pelvic conditions; pregnancy, 
uterine and ovarian tumors (after the removal of which pigmentation 
may regress), (e) Phthisis, malaria, melanosarcoma of the skin, 



OTHER AFFECTIONS OF THE SUPRARENAL GLANDS 881 

exophthalmic goitre or rarely scleroderma. In these conditions, pig- 
mentation of the oral mucosa is rare. 

Treatment. — 1. Supporting and Tonic. — Absolute rest is imperative 
because of exhaustion and proneness to lethal syncope. Alcoholic 
stimulation is poorly tolerated. Careful feeding is necessary because 
of the sensitiveness of the stomach and bowels. Strychnine, arsenic, 
nitroglycerine, faradization and galvanization may be given. 

2. Symptomatic. — Narcotics for pain, gastric sedatives for vomiting 
(v. Gastritis), astringents and opiates for diarrhoea (v. Enteritis) 
should be administered; strong cathartics are always contra-indicated, 
for they may precipitate fatal collapse; one case in the Cook County 
Hospital died suddenly after taking a dram of compound jalap powder. 

3. Organotherapy. — Adrenal extract by mouth has surely helped 
some cases and apparently arrested the development of others (Oliver, 
Sansom, Lloyd, Jones, Osier, Ringer, Langlois, Dupaigne). In 
Adam's review of 97 cases, one-third were benefited, and one-sixth 
recovered. The medullary portion of the gland is best. It may in- 
crease the vascular and muscular vigor or even lessen pigmentation. 
Some practitioners advocate the hypodermatic administration of 
adrenalin chloride, 5j °f 1 to 1,000 in salt solution, on alternate days. 
Some advanced cases are unfavorably affected by organotherapy. 



Other affections of the suprarenal glands are of slight clinical inter- 
est, (a) In developmental anomalies, the glands are sometimes absent 
or hypoplastic, chiefly with other defects, as encephalocele, etc. (b) 
Hypertrophy in one gland may compensate for hypoplasia in the other. 
Supernumerary glands are not uncommon, (c) Atrophy is usual in 
advanced age. (d) Degenerations embrace the parenchymatous, fatty, 
hyaline and amyloid types, (e) Circulatory disorders are hyperemia, 
embolism, thrombosis and hemorrhage, which latter may occur in 
trauma in the new-born, tumors, inflammation and the hemorrhagic 
diathesis. (/) Inflammation, acute and chronic, is uncommon, (g) 
Granulomata, chiefly syphilitic and tuberculous, are rarely primary. 
(h) Tumors, carcinoma, sarcoma (20 recorded, Affleck and Leith), 
and hypernephroma (v. Kidney Tumors) are chiefly of anatomical 
importance. In 23 published operations, the mortality was 50 per 
cent., recurrence developed in 21 per cent., and 29 per cent, recovered 
(in nine months to six years). At the Johns Hopkins Hospital, three 
tumors of the suprarenal glands were successfully operated on (Osier). 
(i) Parasitic disease (echinococcus) is extremely infrequent. 



56 



882 DISEASES OF THE DUCTLESS GLANDS 

(B). DISEASES OE THE SPLEEN. 

Lesions of the spleen are usually secondary. 

ACUTE SPLENIC TUMOR. 

This occurs (a) in acute infections, due either to the local action of 
microorganisms and their toxins, or to toxemic paralysis of the 
splanchnic nerve, which normally controls the vascular supply of 
the organ; it is most common in typhoid, malaria, recurrent fever 
and septic conditions; (b) in acute stasis, usually from portal obstruc- 
tion ; and (c) in embolism (v. i.) and trauma. Symptoms are infrequent; 
much pain usually indicates involvement of the capsule (perisplenitis). 
On objective examination: (a) The spleen may sometimes be seen, 
during deep inspiration, (b) Palpation alone is wholly reliable. By 
the bimanual method and with the examiner sitting at the right side 
of the patient, the edge of the spleen comes in contact with the fingers 
and slips sharply down below them; splenic crenations are seldom 
palpable. A palpable spleen always indicates enlargement, or much 
less often, downward dislocation by pleurisy, emphysema, pneumo- 
thorax or thoracic tumor, (c) Percussion, which is valuable in outlin- 
ing the upper splenic level, is unreliable in determining enlargement, 
for confusion with fecal accumulations is frequent. 

CHRONIC SPLENIC TUMOR. 

Chronic enlargement is symptomatic of (a) chronic infections, as 
malaria, tuberculosis and syphilis, (b) continued portal stasis, (c) 
repeated embolism, (d) blood affections, as leukaemia, pseudoleukemia 
or splenic anemia, and (e) rickets, amyloidosis, neoplasms, cysts, poly- 
cythemia iv.i.), arthritis deformans and chronic acetanilide poisoning. 

EMBOLISM. 

Embolism occurs frequently in the spleen, because of the wide arteries 
and slow current; it ranks second in frequency to kidney embolism. 
It usually develops in the course of acute endocarditis, chronic valvular 
lesions or arteriosclerosis and seldom follows local lesions as sinus 
thrombosis or splenic vein thrombosis. The symptoms vary some- 
what as the embolus is simple or infective; sudden chill, fever, pain 
in the side, acute splenic tumor and perisplenitic friction may develop, 
which with a cause or embolic symptoms in other organs justify a 
diagnosis of embolism. Frequently no distinctive symptoms occur. 



TUMORS AND CYSTS 883 

If septic, symptoms of abscess may be present (v.i.). Treatment is 
wholly symptomatic. 



ABSCESS (SPLENITIS APOSTEMATOSA). 

Abscess of the spleen may result from embolism, trauma or invasion by 
contiguity. Swelling, pain, perisplenitic friction or possibly un evenness 
of surface or fluctuation may mark its development. It is more often 
hidden by the symptoms of the causal focus. It may rupture into 
the pleura, kidney or peritoneum. Aspiration may determine the 
diagnosis, and surgical evacuation is then indicated. 



PERISPLENITIS. 

This affection may be primary or secondary, simple or suppurative, 
an isolated lesion, or part of a chronic peritonitis (see " Icing Liver," 
Chronic Perihepatitis). It usually accompanies the various splenic 
affections already enumerated. Without local peritonitic friction its 
diagnosis is impossible. There is no efficient therapy. 

AMYLOID SPLEEN. 

Its etiology is considered under amyloid liver and kidney. Patho- 
logically its two types are (a) the sago spleen, in which there are amy- 
loid deposits in the vessels of the Malpighian tufts and (b) the more 
important, diffuse amyloid infiltration. It is diagnosticated by (i) 
the etiological factors, (ii) its usually large size, hardness, smoothness 
and thick edge, and (iii) coincident amyloidosis of the liver and kidneys. 

SPLENIC ANEMIA. 

Splenic ansemia (v. Diagnosis of Pseudoleukemia). Springthorpe 
observed six cases in one family. Umber advises operation in every 
case, because he believes that the spleen destroys the red cells. The 
#-rays have been of therapeutic value. 



TUMORS AND CYSTS. 

New growths are very infrequent. They are more often secondary 
than primary. They include carcinoma, sarcoma (of which 19 pri- 
mary cases were reported by Adolph, 1905), enchondroma, and lymphan- 
gioma. They are rarely differentiated from splenic ansemia and like 
affections. The chronic endothelioma of Gaucher clinically resembles 



884 DISEASES OF THE DUCTLESS GLANDS 

splenic anaemia; pathologically, large endothelial cells replace the 
splenic tissue; this can be seen under the microscope or macroscopically 
as in Stengel's case. 

Echinococcus cysts are found in but 0.2 to 3 per cent, of echinococcus 
disease, and usually with concomitant cysts in the liver. Dermoid 
cysts are exceedingly uncommon. Only 13 non-parasitic cysts are 
found in the literature. 

Granulomata (see Tuberculosis and Syphilis). 



RUPTURE OF THE SPLEEN. 

Rupture, may be traumatic or spontaneous; the latter variety has 
been observed in embolism, malaria, typhoid, acute leukaemia, and 
pregnancy. It is more common in India, and tropical climates than 
in temperate zones. Aspiration and even palpation have occasioned 
rupture. The treatment is surgical. Up to 1905, 46 splenectomies for 
rupture were reported (Faltin). 



MOVABLE OR FLOATING SPLEEN. 

Permanent mobility {lien mobile) and dislocation are due to the 
same factors observed in enteroptosis, with which it may be associated : 
(i) lax, elongated or ruptured ligaments (ligamentum gastrolienale, 
phrenicolienale, and most important, ligamentum phrenicocolicum) ; 
(ii) relaxed abdominal walls; and (hi) enlargement and increased 
weight of the spleen operating with the above factors. 

Symptoms. — Symptoms are often absent. Pain or a dragging sen- 
sation is frequent, which is either local or radiates to the thorax, left 
shoulder or legs, similar to that observed in neurotics or women with 
uterine or ovarian disease. There may be headache, insomnia, psy- 
chical alteration, dyspepsia, constipation, menstrual anomalies, vesical 
tenesmus, and parsesthesia in the legs; most of these are neurotic. 
Objectively: (a) The most important sign is palpatory detection of the 
spleen in an abnormal location, (i) It is located most often in the 
left ilio-inguinal region, near the ilium, but may lie just below the 
left costal arch, near the navel, in a hernial sac, in the pelvis, or above 
the pubes. (ii) Its hilum usually points upward, either directly, if it 
lies across the vertebrae or in the pelvis, or with slight inclination to 
the right or left if it lies to one side, (hi) The form, notches and pos- 
sibly the pulsating vessels are those of the spleen, (iv) In size it is 
usually enlarged, either from some causal hypertrophy or some later 
congestion; torsion of its pedicle may lead to softening, atrophy, 
gangrene or even liberation of the spleen as a free body, (v) As a 
rule it can be replaced, and its position changes with posture; peri- 
splenitis, causing a friction rub, may result in firm adhesions to the 
colon, bladder, rectum, or uterus, thereby causing great or insuperable 



SPLENOMEGALY, WITH CHRONIC POLYCYTHEMIA, CYANOSIS 885 

diagnostic difficulty; in such cases the spleen is dislocated, but ceases 
to "wander." (b) The spleen is absent from its normal location, the 
splenic area being replaced by tympany from the colon (which changes 
to dulness when water is introduced into the colon), (c) Pressure 
symptoms, intestinal obstruction, gastric dilatation, vesical and rectal 
compression may be noted. 

Diagnosis. — Diagnostic confusion with floating kidney, and pedun- 
culated ovarian tumors is rather infrequent, when the abdomen and 
pelvis are carefully examined. The author knows of three laparotomies 
performed for supposed uterine or renal disease, in which abundant 
adhesions rendered differentiation impossible. On the other hand, 
a hard, immovable suprapubic tumor was correctly diagnosticated 
as leukemic spleen from the glands and blood findings. 

Treatment. — (a) Bandages are more difficult to apply than for 
movable kidneys, though some cases can be benefited by them, (b) 
The spleen may be replaced by operation, and its vicinity well packed 
with gauze; the resulting adhesions often retain the viscus. (c) 
Splenopexis (Rydygier) may be performed, the spleen being sewed 
in place or deposited in a peritoneal pocket. Stierlin (1897) collected 
32 operated cases, in which the mortality was 6 per cent, id) Splenec- 
tomy (see Pseudoleukemia) may be performed as a last resort, the 
mortality being about 27 per cent. 



SPLENOMEGALY, WITH CHRONIC POLYCYTHEMIA, AND 

CYANOSIS. 

This condition has been described particularly by Osier, Weintraud 
and Turck. About 34 cases are reported up to 1905. (a) The red 
cells are increased, even to 9 or 13 million (polycythemia rubra or 
polyglobulism) ; the haemoglobin may reach 150; the white cells number 
from 4,000 to 31,000. The viscosity, specific gravity and volume of 
the blood are increased, (b) There is chronic cyanosis, without adequate 
cause and (c) splenomegaly. There may be headache, constipation, 
vomiting, and an hemorrhagic diathesis. The arterial tension may be 
increased and the heart may hypertrophy. De Lee sent the author 
what appeared to be a forme fruste, a case with splenomegaly and 
cyanosis but without polyglobuly. The etiology is obscure; in about 
one-third of the cases it was tuberculosis of the spleen and 8 of the 11 
operated cases recovered; stasis may be the cause, e.g., a malignant 
growth compressing the superior vena cava; it seems probable that 
in most cases the cause is an undue activity of the bone-marrow. The 
treatment is arrays, venesection, iodide of potash or splenectomy. 



V 



886 DISEASES OF THE DUCTLESS GLANDS 



(C). LYMPHATISM (STATUS LYMPHATICUS). 

Lymphatism is a condition in which there is hyperplasia of the 
various lymphoid and kindred tissues, and a tendency to sudden 
death. It is also known as the constitutio lymphatica, status thymicus 
and status lymphaticus. 

Its etiology is .most obscure. The affection is rare and occurs most 
often in women and children. Hedinger observed it as a familial 
affection. 

Symptoms. — 1. There is lymphoid hyperplasia, (a) The lymph 
glands of the chest and abdomen are more often involved than the 
external, cervical, axillary or inguinal glands, (b) The tonsils, naso- 
pharyngeal, lingual and intestinal lymphadenoid tissues are fre- 
quently hyperplastic. (c) Moderate splenic enlargement is usual. 

(d) The thymus is swollen, sometimes giving retrosternal dulness. 

(e) The bone-marrow often changes to a reddish color. 

2. Associated findings may include hypoplasia of the heart and 
aorta, thyroid enlargement, poor development, infantilism, rickets, 
tetany, and laryngismus. 

3. Sudden death is often the first evidence of the condition and may 
occur without seemingly adequate cause, (a) It has occurred during 
or after anaesthesia, especially with chloroform. In one case, a patient 
with enlarged glands died suddenly after receiving but 20 drops of 
chloroform. (6) Operations with local anaesthesia have also been fatal. 
(c) Administration of antitoxin has caused death, as in the well- 
known case in Prof. Langerhans' family, (d) It may occur while 
bathing or after falling in the water, (e) Sudden deaths during con- 
valescence from acute infections, or some collapses during hydro- 
therapeutic treatment (Escherich) may be attributed to the lymphatic 
constitution. (/) Children with eczema may die suddenly; lymphatism 
causes 75 per cent, of these deaths. It is said to be due to cardiac 
excitability (Kundrat),to lessened physiological resistance with a ten- 
dency to heart paralysis (Paltauf), and to a toxic condition (Blumer, 
who suggests the term lymphotoxism.) 



(D). DISEASES OF THE THYROID GLAND. 

GOITRE. 

Definition. — Hypertrophy of the thyroid gland. Sporadic cases are 
common in Europe and America. Goitre occurs endemically in 
Switzerland and Italy, though we have no knowledge of its cause; 
the drinking-water has been thought causal. It is usually acquired, 
and is seldom congenital. 



GOITRE 887 

There are three main forms: (a) the parenchymatous or follicular 
type, with more or less symmetrical enlargement, and formation of 
colloid material in the hyperplastic follicles; (b) the cystic; and (c) 
vascular or congestive type, with dilatation of the bloodvessels. The 
last form borders closely on those almost physiological variations 
in the organ, which are observed at puberty, in defloration, pregnancy, 
chlorosis and psychical trauma. 

Symptoms. — 1. The thyroid enlargement may be diffuse, as in the 
soft, symmetrical and moderately vascular form, or partial or nodose, 
implicating but Qne lobe or the isthmus. In most cases there are only 
local findings. 

2. Compression symptoms are not common. The carotid artery 
and jugular vein are pushed to one side, and the sternomastoids 
become thin. The trachea may be compressed, its lumen becoming 
shaped like a sword scabbard; asthma, dyspnoea, bronchiectasis and 
dilatation of the right ventricle follow stenosis of the air-passages. 
Laryngeal paralysis occurs in over 10 per cent. Fraenkel states that 
in 25 per cent, of cases in which there is tracheal stenosis, there is 
also laryngeal paralysis. From the isthmus or lower horns of the 
thyroid, goitres may grow in a retrosternal or retroclavicular direction 
(5 to 10 per cent.) causing compression of the vagus, sympathetic 
nerves and vena cava. A goitre may disappear into the chest with 
each inspiration and appear on expiration (goitre en dedans). It may 
become incarcerated in the chest. 

3. An aberrant or accessory thyroid may occasionally form a tumor, 
anywhere from the tongue to the aorta, and from the spine to the 
anterior chest wall, in the retropharyngeal or retrocesophageal tissues 
(causing dysphagia or dysarthria), in the trachea, larynx, root of the 
tongue, pleura or mediastinum; it may compress an entire lung. 
Storrs (1904) collected 32 lingual goitres; there are three cases in 
the literature of retrosternal accessory thyroids, which became cystic 
and calcarious (Collins, 1905), and fourteen which were intratracheal 
(Pfeiffer, 1905). 

4. Sudden death may occur in large goitres; it may be due to pres- 
sure on the vagus, spasm or oedema of the glottis, sudden hypersemia 
of the gland and pressure on the trachea, hemorrhage dissecting 
into the chest, or status lymphaticus. 

Diagnosis. — Confusion is possible with tumors as sarcoma, carci- 
noma or adenoma, for whose differentiation and symptoms reference 
to surgical treatises should be made. There are 23 cases in the 
literature of echinococcus cysts. In 83 per cent, of cases, cancer de- 
velops from a preexisting goitre; early metastases are specially com- 
mon and characteristic; only 10 per cent, recovered among 110 
operations (Madelung). There are 20 cases recorded in which metas- 
tases throughout the body occurred from benign tumors of the thyroid 
(chondroma or myxoma). Thyroid inflammation (strumitis) is usually 
secondary (metastatic) or traumatic, rarely primary; it may occur in 
sound or goitrous glands; it is most often due to the streptococcus 



888 DISEASES OF THE DUCTLESS GLANDS 

but may be caused by the colon, typhoid, pneumonia, diphtheria or 
other organisms. 

Treatment. — In regions where goitre is prevalent, the drinking 
water should be boiled. Medical treatment is of uncertain value. 
Iodine may be used externally or by injection (Maunoir, 1825). 
Potassium iodide (Coindet, 1820) is beneficial in some subacute cases, 
according to Bruns, in 75 per cent.; Kraus found it particularly 
beneficial in the vascular type, with cardiovascular symptoms, as 
moderate tachycardia and full arteries. The arrays are valuable in 
some cases. Thyroid extract is occasionally beneficial. Surgical 
treatment is indicated in large or growing goitres. Reverdin's collect 
tion of 6,103 operations shows a mortality of 2.8 per cent., and in 
Kocher's series, now several thousand, but one death occurred in 
each 600 operations. See Cachexia Thyreopriva, under Myx- 
cedema. 

EXOPHTHALMIC GOITRE. 

Definition. — A malady probably due to excessive activity of the 
thyroid gland, and characterized by three cardinal symptoms, exoph- 
thalmos, enlarged thyroid and tachycardia, and by other accessory 
symptoms, as tremor, increased metabolism, and ocular, vascular, 
digestive and other symptoms. It was first described in England by 
Parry (1786), and Graves (1835), and later in Germany by Basedow 
(1840). The claims of the Italians, that Flajani (1800) first described 
the affection, are ill-founded. 

Etiology. — Its etiology is obscure, but (1) the most probable cause 
is over-activity or perversion of thyroid secretion (Moebius, Johnston 
and Greenfield). Exophthalmic goitre contrasts sharply with myx- 
cedema (y.i.) of which the anatomical basis is thyroid atrophy. The 
outlines of this theory can be best presented by comparing these 
antithetic conditions; 

Exophthalmic Goitre. vs. Myxcedema. 

(a) Hypertrophy of gland; excessive Atrophy; deficient (hypothyrea) or ab- 

internal secretion (hyperthyrea sent secretion (athyrea). 

or thyroidism). 

(b) Increased nervous excitability. Dulness, apathy, cretinism. 

(c) Vascular erythrism; flushed, moist, Skin dry, thick and cool, and pulse slow. 

warm skin; rapid pulse. 

(<2) Increased diuresis and active metab- Decreased, 
olism. 

(e) Thyroid extract increases symp- Thyroid extract improves or cures 
toms ; it may produce in normal 
individuals symptoms like those 
of exophthalmic goitre, tachy- 
cardia, tremor, even exophthal- 
mos. 



EXOPHTHALMIC GOITRE 889 

(/) Surgical (partial) excision relieves, Some cases result from removal of thy- 

and often cures. roid. Transplantation of new gland 

improves or cures. 

(g) Exophthalmic goitre (glandular hypertrophy with excessive function) may 
occasionally become myxcedema (insufficient function from glandular 
atrophy) . 

2. Other etiological explanations are less probable, as (a) vasomotor 
neurosis (Charcot) ; (6) lesions in the corpus restif orme of the medulla, 
based on experiments by Filehne; (c) lymphatic disease and id) dis- 
ease of the parathyroid glands. 

3. Disposing or exciting factors are: (a) Sex; in Eschner's series 
of 200 cases 80 per cent, were women (95 per cent, in other series). 
Fibroids, pregnancy, and puberty are sometimes promoting factors. 
(b) Age; most cases occur between the twentieth and thirtieth years. 
Barrett (1904) could collect only 42 cases in persons under fifteen 
years, (c) Psychical trauma, as fear, excitement or concussion, are 
sometimes apparent causes, (d) Anaemia, debility, excesses, neuro- 
pathic family tendencies and occasionally chorea, hysteria, epilepsy 
or psychoses favor its development, (e) After thyroidectomy, symp- 
toms resembling those of exophthalmic goitre may develop; this 
postoperative thyroidism is rare. 

Symptoms. — Cardinal Symptoms. — 1. Tachycardia is usually the 
earliest cardinal symptom, and is almost always present. The pulse 
ranges from 100 to 120, and in severe cases to 140 (160 or even 200). 
It is associated with other cardiovascular symptoms, as (a) increased 
cardiac action, manifested by a diffuse apex and cardiac impulse, 
sharp tones sometimes heard at a distance of several feet (Graves), 
and hypertrophy chiefly of the left ventricle which is ultimately com- 
plicated by dilatation; (b) a functional (systolic) murmur over the 
apex; (c) palpitation, which usually antedates tachycardia and is an 
evidence of intoxication (thyroidism); (d) vascular symptoms; a pulse 
rather weaker than the apex beat; active arterial pulsation in the 
carotids, and abdominal aorta; systolic capillary pulsation in the 
fingers, forehead or even in the retina, palate, liver and spleen; even 
the peripheral veins may pulsate; (e) irregular and failing heart action 
occurs late and only in severe cases. Hemorrhages, notably epistaxis, 
are not uncommon. 

2. Exophthalmos is usually a later symptom than tachycardia or 
sometimes than the goitre. It is present in about 90 per cent, of cases 
and results from dilatation of the orbital vessels. In developed cases 
the protrusion of the eyeballs, and the staring, fixed expression are very 
characteristic (exophthalmos may also occur in extreme myopia, tumors 
of the orbit, and sympathetic irritation). The condition is generally 
bilateral, though often unequal; in one instance, the author saw uni- 
lateral exophthalmos with homolateral goitre. The eyelids are unable 
to cover the eyeball entirely, and a rim of the white sclera shows 
about the iris. The protrusion may be very extreme, even amounting 



890 DISEASES OF THE DUCTLESS GLANDS 

to dislocation of the bulb; in these cases it may be necessary to sew 
together the lids to prevent corneal ulceration and loss of the eye by 
panophthalmitis. Under this topic may be mentioned the associated 
eye-symptoms; they are (a) von Ch-aefe's sign, which is the failure of 
the upper lid to follow the eye-ball when it is rolled downward; it is 
present in at least 33 per cent., and is of considerable diagnostic value, 
though present also in Thomsen's disease. (6) Stellwag's sign, which 
is rarely absent, is widening of the interpalpebral fissure with infre- 
quent winking; it also occurs in mania, and in old age. (c) Moebius' 
sign consists of weakness of the internal recti, whereby convergence 
is less complete, or unsustained, when a finger on which the eyes are 
focused is brought close to the nose; it occurs also in other conditions, 
as paretic dementia, (d) Becker's sign consists of pulsation of the 
retinal vessels, (e) In Joffroy's sign, the patient's forehead remains 
smooth (instead of becoming wrinkled) when he glances upward 
with the head bent somewhat downward. Eye paralyses and retinal 
or pupillary changes are infrequent. 

3. The goitre is rarely an initial symptom, and usually develops 
later and in a remittent fashion, i.e., swelling, recession and renewed 
swelling. It is present in 92 per cent, (a) Its typical form is vascular, 
though it may develop upon any of the ordinary forms of goitre, as 
in an acute fatal case, seen in 1905, with Dr. Dorsey of Streator, in 
which exophthalmos, tachycardia, and thyroid thrills and murmurs 
developed in a chronic cystic goitre. Acute thyroidism may develop in 
thyroid malignancy. The goitre is smaller than the ordinary bron- 
chocele; it is diffuse or oftener more developed on the right side (an 
accentuation of physiological proportions) ; and microscopically shows 
the dilated vessels alluded to above, and hyperplasia of the parenchym- 
atous tissue, in which the colloid matter is scanty or resembles the 
embryonal form (not staining with eosin); in the later stages some 
fibrous tissue may develop, (b) It is usually soft, elastic, variable in 
size from time to time, pulsating on inspection, thrilling on palpation, 
and revealing on auscultation a loud systolic bruit, or a double mur- 
mur which, according to Guttmann, is pathognomonic. 

Accessory Symptoms. — (a) Tremor, described first by Basedow, is 
classified as a cardinal symptom by some writers, as Charcot and 
Marie. It is present to some degree in most cases, and is conspicuous 
in 50 per cent. It is characteristically fine, regular and rapid, number- 
ing 8 or 9 vibrations to the second. It affects the wrist more than 
the fingers; sometimes it affects the trunk, (b) There may be nervous 
symptoms. Some cerebral symptoms are usual, as headache, vertigo, 
impaired memory, insomnia, irritability, depression or change in dis- 
position. Psychoses are infrequent, as the mania which is sometimes 
observed in fatal cases. Choreiform movements were described by 
Kahler. Muscular weakness is usual, as "giving way of the legs" 
(Charcot), and weakness of the respiratory muscles (scant inspiratory 
increase in the chest measurement, Bryson's sign). The reflexes are 
often increased. Rheumatic pains may be noted. Vasomotor symp- 



EXOPHTHALMIC GOITRE 891 

toms are common, as violent reddening of the face, subjective warmth, 
dry mouth, sweats of a peculiar, penetrating odor, or intermittent 
swelling of the joints. Rarer complications are cerebral paralyses, 
tabes, syringomyelia or other neuroses, (c) Respiratory symptoms 
include dyspnoea and dry cough. The author has seen two incipient 
cases diagnosticated as phthisis, (d) There may be digestive symp- 
toms. Severe (nervous) vomiting and diarrhoea may simulate organic 
disease; their persistence is ominous, (e) Cutaneous symptoms may 
be marked. Pigmentation may be extreme (Drummond, Chvo- 
stek). Pigmentation of the eyelids, vasomotor oedema, urticaria 
(particularly in acute cases), vertigo, itching, and falling of the hair 
may also occur. A peculiar fulness above the clavicles may develop, 
sometimes with pain in the neck. The electrical resistance of the 
skin is decreased, perhaps to one-fifth of the normal (Charcot, Chvo- 
stek, Vigouroux); it is probably occasioned by profuse sweating and 
has no pathognomonic importance. (/) There may be constitutional 
symptoms. Emaciation and anaemia are common, especially in blondes. 
Metabolism is almost always increased ; this is evidenced by the nitrog- 
enous excretion, increased diuresis and the frequent, slight, but wholly 
atypical, elevation of temperature; these symptoms may be inter- 
mittent (Huchard). Amenorrhcea, albuminuria, glycosuria, persist- 
ence of the thymus gland, and the occasional hyperplasia of the spleen 
are difficult to explain. 

Diagnosis. — The diagnosis is unequivocal when the cardinal triad 
of symptoms is present, reinforced by the secondary symptoms. 
Atypical forms (formes frustes) may cause confusion, but careful 
watching of the clinical course usually settles all doubt. The affec- 
tion is often incorrectly diagnosticated in young girls at puberty, in 
whom thyroid turgescence, moderate tachycardia and vascular excit- 
ability occur without particular significance. Incipient tuberculosis 
and neurasthenia may be simulated. 

Course and Prognosis. — (a) The onset is usually insidious and the 
course chronic. Remissions are very common. Chronic cases some- 
times begin rather acutely. Acute cases are unusual; they occur 
chiefly in men; Lloyd records a case which was fatal in three days, 
and Trousseau one which was fatal in eight days. The author has 
seen three cases in which death occurred in from two to H\e weeks. 
The acute type is usually fatal, though Solbrig mentions a recovery 
after ten days. (6) Death occurs in 12 per cent, of cases; it is almost 
always due to cardiac failure, from hypertrophy passing into dilata- 
tion, (c) The outlook is best in the less typical (rudimentary) forms. 
(d) Complete recovery is rare, though 20 to 50 per cent, of cases 
improve (relative recovery). (e) Unfavorable prognostics are its 
occurrence in the very young and in men, emaciation, extreme tachy- 
cardia, persistent vomiting or diarrhoea, fever, corneal disease, lymph- 
atism and intercurrence of myxcedema (v.i.). 

Treatment. — 1. General. — Rest is the first indication. Travel, so- 
journ at the various springs and resorts, gymnastics and excitement 



892 DISEASES OF THE DUCTLESS GLANDS 

are always injurious. A simple diet and interdiction of all stimulants 
(alcohol, coffee, tea, tobacco) are essential. A quiet life at a very 
moderate elevation or at the sea-side is very beneficial. 

2. Drugs. — Except for symptomatic indications, drugs have a very 
limited use. The heart tonics are disappointing; digitalis usually 
fails to slow the heart, and strophanthus and spartein sulphate are 
rather more efficient but do not adequately control tachycardia. Bella- 
donna, in the largest physiological doses (until it produces mydriasis 
and dry mouth), is recommended by Gowers; some cases are dis- 
tinctly benefited, and in personal experience, the annoying palpitation 
and abdominal throbbing are most relieved. Ergo tin, quinine, 
arsenic, iron and strychnine are of uncertain value, but the latter 
seems rather more beneficial ; iron is apparently useful only in chlorotic 
girls (Moebius) and is directly injurious in men, for it aggravates 
digestive and vasomotor disturbance. Constant application of an ice- 
bag to the heart is very helpful; it relieves palpitation and somewhat 
slows the heart rate. 

3. Electricity. — This is chiefly valuable as a suggestive remedy, 
according to some writers ; galvanization is particularly recommended 
by Erb, who uses the anode over the cervical spine and the kathode 
over various peripheral areas. Electrotherapy effects only transient 
results. 

4. Organotherapy. — Thyroid extract aggravates the symptoms in 
all save a very few cases. Thymus extract has apparently helped some 
cases, but most recent reports concur with the rather negative results 
obtained by Mackenzie and Kinnicutt. The use of serum or milk 
from dethyroidated animals is still in the experimental stage; Baumann 
(1895) demonstrated that the thyroid gland contained an iodine body 
which Ross proved was the main functional constituent of the organ. 
The active element of the gland presents two clinical phases: (a) it 
neutralizes toxins (failing in which, myxcedema results), and (b) if not 
itself neutralized, Basedow's disease results; to neutralize the hyper- 
thyrea of this disease, it was suggested that the serum of thyroidec- 
tomized animals be used (Ballet, Enriquez, Lanz, Burghart and 
Blumenthal) ; some good results have recently been obtained (Rogers). 

5. Thyroidectomy. — The earlier objections to partial thyroidectomy 
on the grounds that many operated cases were ordinary goitres, or 
that improvement often occurs spontaneously or medicinally, are now 
weakening because of convincing surgical statistics. The average 
mortality is about 15 per cent. (Mayo, Oppenheim). In Kocher's 
large experience of 167 operations (1906), naturally on severe types, 
only 5 per cent. died. The Mayos' last series shows 8 per cent, mor- 
tality; they consider general preferable to local ansesthesia. Death 
may also occur under local anaesthesia which latter is a very unpleasant 
procedure. Removal under nitrous monoxide gas gave excellent results 
in two of the author's cases. The results of operations by Kocher, 
Kummell, Friedheim and others show approximately the following 
results; mortality 5 per cent, (as against 12 per cent, under medical 



CRETINISM 893 

treatment) , complete recovery (which is rare under expectant therapy) 
in 70 per cent, and partial recovery in 25 per cent. Kocher prefers 
trying the x-rays first and then proceeding by stages, first ligating the 
thyroid arteries (after which tetany may occur and once within half 
an hour), and later performing partial thyroidectomy; the danger of 
a " heart" death is avoided by relatively early operation. Hirst states 
that the mortality of operation, for any indication, in an exophthalmic 
subject, is increased 15 per cent. 

Division of the cervical sympathetic is inadvisable. 



MYXCEDEMA. 

Definition. — Myxcedema is a chronic constitutional disease, char- 
acterized (i) by loss of thyroid function (athyrea), (ii) by my oedema 
(an elastic cedematous change in the subcutaneous tissue), (iii) by 
cachexia or (iv) by cretinism (mental failure). It was described by 
Gull (1873) as a cretinoid manifestation, and later by Ord (1877), 
in England, and in France by Charcot, Bourneville, d'Olier and others. 

The symptoms vary as to cause and combination, whence (a) 
cretinism, (b) adult myxcedema, and (c) operative myxcedema will be 
considered separately. 

Etiology. — The thyroid may be aplastic, hypoplastic, cirrhotic 
from an infective sclerosing thyroiditis (syphilis, tuberculosis, rheu- 
matism, or erysipelas), or hypertrophied (goitre) or it may be removed 
by operation, but in all cases the thyroid function (internal secretion or 
antitoxic action), is suspended or lost. 



CRETINISM. 

Cretinism may be congenital, in which instance life is not long 
protracted; it usually develops in the first year, and is noticed near 
the time of weaning (infantile form); it may develop between the 
fourth year and puberty (juvenile form). The endemic form occurs 
in regions where goitre is prevalent, in Switzerland, Italy, France, 
Great Britain, Spain and Sweden; according to Kocher, when both 
parents are goitrous, the child is invariably a cretin, is myxcedematous 
and may also have goitre. The sporadic form may develop from 
thyroid aplasia, sclerosing thyroiditis or from goitre. In 1901, 100 
cases were collected in America. 

Symptoms. — In the last part of the first, or in the second year of 
life, retardation of mental and physical development is apparent. 
The head is disproportionately large, the fontanelles persist, the fore- 
head is narrow, and the base of the skull is shortened. The face is 
turgid, pale, and imbecile, the lids are swollen, as are the nose, the 
protruding tongue, and pouting lips. Dentition is retarded and caries 
is frequent. The skin loses its tone and is dry, and the hair is thin. 



894 DISEASES OF THE DUCTLESS GLANDS 

The neck is short, which condition is accentuated by supraclavicular 
deposits of fat. The abdomen is large and pendulous; umbilical 
hernia is very frequent. The body is dwarfed and the extremities 
are short, stumpy, and weak or helpless. Metabolism is slow, the 
gaseous interchange being reduced to 50 or 60 per cent, of the normal. 
Diagnosis. — (a) The mental alteration is marked, though mild com- 
pared with the grimaces, grinding of the teeth, and compulsory move- 
ments caused by gross lesions of the brain, (b) In hyperplasia of the 
bone cartilages (chondrodystrophia fetalis), there is great enlargement 
of the head and joints, dwarfing of the body, and shortness of the 
extremities (micromelia), but no essential mental change; court fools 
were probably of this type, (c) Infantilism concerns only the infantile 
appearance of the genitalia, and the absence of the primary and second- 
ary evidences of sex; general malnutrition, aplasia, and cretinism are 
absent, though some cases of infantilism are due to thyroid hypo- 
plasia. 

MYXCEDEMA OF ADULTS. 

Symptoms. — Myxcedema spontaneum adultorum, or cachexie pachy- 
dermique (Charcot) is characterized by (1) thyroid atrophy, (2) myx- 
cedema (pachydermia), (3) intellectual and physical weakness, and 
(4) certain accessory symptoms. It is most frequent in England and 
France. Most cases occur in persons between thirty and fifty years 
of age. 

1. Thyroid Atrophy. — This is difficult to detect clinically. It is 
less a clinical than a histological condition, as evidenced by the lack 
of function sometimes observed in gross enlargement of the gland; 
Magnus Levy, in 34 cases observed by him, found the thyroid hard 
and large in 5 cases. Eighty-six per cent, occurs in women, and it 
is possibly related to the uterine functions or to the physiological 
congestive, thyroid enlargement observed in women. It may be 
hereditary or familial. It sometimes occurs in a family (or in individ- 
uals) in which there are cases of exophthalmic goitre. 

2. Myxcedema. — In a few instances, much mucin has been found 
in the skin and subcutaneous tissues. These structures are inelastic, 
semigelatinous and semicedematous, but do not pit upon pressure; 
the skin is pale, waxy, dry, rough, firm, and its electrical resistance 
is increased; the hair and teeth may fall out and the nails thicken 
and break. The facies is somnolent, coarse, and swollen, and the 
features are individually changed, rather resembling those of a cretin ; 
the cheeks are patchy-red, pendulous and tremble like jelly, and the 
tongue is big. The supraclavicular tissue is enlarged in lumps and 
rolls, though this is also observed in healthy persons (Verneuil's 
pseudolipomata). S. Kuh observed a painful swelling over the clavicle 
alone, which rather resembled keloid. The hands and feet are infil- 
trated. The swellings may change rapidly. The oral mucous mem- 



CACHEXIA STRUMIPRIVA OR OPERATIVE MYXCEDEMA 895 

brane is dry and thick, sometimes also the pharynx, larynx and even 
the rectum; polypi are frequent and secretion of tears is scanty. 

3. Mental Weakness. — Intellectual and physical weakness is ap- 
parent. Somnolence is more frequent than insomnia. Charcot com- 
pares the condition to hibernation. Headache is common. The 
patient is apathetic, irritable, weak in memory, and slow in thought, 
speech and movement; sometimes delirium and mania precede the 
ultimate dementia. The gait is clumsy (" hippopotamus gait") and 
muscular fatigue follows moderate exertion. 

4. Other Symptoms. — -The accessory symptoms are variable, as 
cardiac hypertrophy, arteriosclerosis, palpitation; small, sluggish 
pupils, tremor, vertigo, night terrors, sensitiveness to cold; indiges- 
tion and constipation; anaemia; amenorrhcea; scanty urine with 
little urea, and low specific gravity, sometimes albuminuria, and less 
often glycosuria; hemorrhages, especially from the uterus; and subnor- 
mal temperature. The thymus is usually enlarged, sometimes the 
hypophysis; Hunt describes it with adrenal tuberculosis. 

Course. — The course is chronically progressive, and covers ten to 
twenty years. Remissions may occur in the warm weather, from 
change to a milder climate or during pregnancy. In the last stage, 
the myxcedema often disappears. Transient cases of acute myxcedema 
have been observed by Sollier, Osier, and others. Osier in 1898, 
reported an acute case with melaena, mania, glycosuria, tachycardia, 
and death in six months. Sudden death is occasional but most 
patients die of intercurrent tuberculosis or acute infections. 



CACHEXIA STRUMIPRIVA (THYREOPRIVA) OR OPERATIVE 

MYXCEDEMA. 

Horsley reported that myxcedema, tetany contractures, apathy, and 
coma occurred in the monkey after complete thyroidectomy; when 
kept warm, the monkeys did not manifest myxcedema, but a species 
of cretinism. Cachexia follows extirpation in man and herbivora; 
convulsions develop in carnivora, resulting from the fact that the 
antitoxic elements of the thyroid are not present to neutralize the nuclein 
of ingested meat. The toxaemia strumipriva is manifested by anaemia 
(2 million red cells), leukocytosis (30, to 38,000) and degeneration in 
the walls of the bloodvessels. Kocher (1882) observed cachexia 
strumipriva in about 17 per cent, of 408 cases, more often after the 
complete than after the partial operation. Reverdin made similar 
observations, and Eiselberg reported it in about 23 per cent, of com- 
plete excisions made in Billroth's clinic. Accessory thyroids (v. Goitre) 
may avert this operative complication. The author knows of two 
instances in which removal of an accessory lingual thyroid (under 
a mistaken diagnosis), caused myxcedema. SchifY (1884), and later 
Eiselsberg succeeded in curing operative myxcedema by transplanta- 
tion of a thyroid. Bircher (1889) first successfully made a trans- 



896 DISEASES OF THE DUCTLESS GLANDS 

plantation in the human being. Unfortunately, the function of the 
transplanted gland is very seldom maintained, though recently Cris- 
tiani reports excellent results. 

In some cases, ablation of the thyroid gland produces tetany (tetania 
thyreopriva). Vassali and General! maintained that absence or abla- 
tion of the thyroid causes cachexia, and trophic disorder, and that 
absence or ablation of the parathyroid glands causes tetany (without 
cachexia). The parathyroids have maintained life thirty-seven years 
when the thyroid was congenitally absent, and Kishi believes that 
after thyroidectomy, the parathyroids actually become thyroid tissue. 
In thyroidectomy the upper parts of the lateral and middle lobes 
should be removed in order to spare the parathyroids which are located 
alongside the lower part of the lateral lobes. 

Treatment of Cretinism, Myxoedema and Cachexia Thyreopriva. — 
For these allied conditions we possess in the thyroid extract one of 
the few actual specifics of medicine, and most cases of cretinism, adult 
myxoedema and operative myxoedema can be cured — in a sense we can 
seldom employ this term. Horsley's pupil, Murray, first used the 
thyroid extract hypodermatically; this method soon gave way to its 
administration by mouth, advocated by Horwitz of Copenhagen (1892), 
and Mackenzie and E. L. Fox in London. The powdered extract 
should be prepared from the glands of young sheep, for the thyroid 
soon atrophies in older animals. Beginning with gr. ij t.i.d., the dose 
may be increased to gr. v or even xv. In a short time the evidences 
of increased metabolism appear, as loss of weight, increased diuresis, 
increased urea and elevation of bodily temperature; normal growth is 
stimulated, myxoedema and cretinism disappear, the pulse becomes 
full and lively, the skin moistens and regains its lustre and in every 
regard the results are magical. In some instances toxic effects (thyroid- 
ism), are apparent, as tachycardia, nervousness, delirium, dyspnoea, 
palpitation, flushing, sweating, tremor, less often tonic spasms and 
rarely exophthalmos, softening of the bones, particularly in young 
rhachitic subjects, or even death; these symptoms are allied to those 
of exophthalmic goitre (hyperthyrea) ; thyroidism is seemingly more 
frequent in myocarditic and arteriosclerotic subjects. Ewald thinks 
that administration of arsenic lessens the liability of thyroidism, which 
after all is an infrequent condition. Larger doses may be given in 
winter than in summer. At first large doses are indicated, and later, 
after relief is obtained, smaller doses should be given, averaging gr. j 
to ij, or whatever size experience in the individual case may determine. 
Relapses are common after withdrawal of the extract, and in most 
cases it becomes rather a food than medication. Change of climate, 
warm baths, and sometimes pilocarpin hydrochlorate gr. to, hypoder- 
matically, are of decided benefit. A milk diet, or a salt-free diet, is 
also advocated. 



DISEASES OF THE THYMUS GLAND 897 



(E). DISEASES OF THE THYMUS GLAND. 

The thymic functions are unknown. Among other hypotheses, it is 
said that the thymus is concerned in neutralizing infection, that it 
concerns certain vegetative functions as the growth of bone, and that 
it bears some relation to cerebral function. Its secretion in the first 
two years of life is milky and contains iodine, cells, and a molecular 
subtance. It weighs two to four drams (7 to 13 gm.) at birth, about 
an ounce (24 to 30 gm.) in the second year, after which it wastes, 
weighing but one dram (3 gm.) at twenty-five to thirty years of age. 

There is an intimate, though obscure, relation between the thymus, 
thyroid, pituitary body, parathyroids, testes, ovaries and possibly also 
the bone-marrow. The thymus wastes as the testicles and ovaries 
develop. Thymic extract causes a fall in blood pressure, cardiac 
acceleration and, in large doses, fatal collapse. 



(a) Hemorrhages into the thymus may be found in cases of con* 
genital syphilis and in asphyxia of the new-born, (b) Thymic cysts 
have been described. Chiari claims that 50 per cent, of them are 
merely accentuation of the normal findings, in which the lymphoid 
elements overgrow into the convolutions of the gland, (c) Abscess 
of the thymus has been described by Dubois (1850), but is often 
mistaken for softened gummata, cysts and postmortem softening. 
(d) The most frequent tumors are sarcoma and lymphosarcoma. 
Less frequent are dermoids and granulomata. 

(e) Persistence of the gland after puberty is an infrequent and wholly 
obscure condition; sometimes it may be identified by an area of 
dulness reaching upward from the third rib and an inch or so to either 
side of the sternum. 

(/) Some cases of "persistent thymus" are hypertrophy, which is the 
most common thymic lesion, (i) Plater (1614) associated enlargement 
of the thymus with sudden death. Grawitz, Jacobi, and others have 
described cases of thymic hyperplasia which has caused sudden dysp- 
noea, usually in infants, followed by early death; the idea is advanced 
that the gland presses on the vagus, cava, or trachea. The cases are 
thought to be lymphatism, as are the cases described by Nordmann, 
Recklinghausen, Rolleston, Paltauf and Keyer, who collected eight cases 
of sudden death in robust young men while bathing, by Kundrat, who 
found thymic hyperplasia in 10 cases of death from chloroform, and 
by Schlomicher's similar series, (ii) The existence of thymic asthma 
(Kopp, 1830), also known as Millar's asthma, was denied by Fried- 
leben (1848). Though asthma thymicum is probably a nervous affec- 
tion (laryngismus stridulus) in most cases, still in some rare instances, 
the enlarged gland may actually flatten the trachea (Summa and 
Benecke), as the distance between the sternum and spine is but 
little more than an inch; Siegel, in a case of thymic asthma, stitched 

57 



DISEASES OF THE DUCTLESS GLANDS 

the gland to the skin, which relieved all symptoms; and Konig and 
Ehrhardt each cured a case by partial excision of the gland. Hoch- 
singer (1905) found 20 cases of thymic stridor in 26 enlarged thymi 
in children; enlargement was determined by the arrays, (iii) Hyper- 
plasia has been frequently or constantly found in Graves' disease by 
Ord, Mackenzie, F. Kraus and Hektoen. It is occasionally hyper- 
plastic in acromegaly and epilepsy. 



(F). DISEASE OF THE HYPOPHYSIS: ACROMEGALY. 

Acromegaly (large extremities), first described by Marie (1886), is 
a nutritional affection, probably caused by disease of the hypophysis, 
and marked clinically by unusual overgrowth of the bones, tissues 
of the face, hands and feet, and by general symptoms, glycosuria, and 
sexual disturbance. 

Etiology. — The hypophysis is almost always diseased. In 1902, 
Woods-Hutchinson collected 262 cases; in 77 autopsies, the gland 
was diseased in 73. The process may be hyperplasia, adenoma or soft 
malignant sarcoma, less commonly colloid degeneration, fibrosis, soft- 
ening or hemorrhage. Dean Lewis found hyperplasia of the chromo- 
phile cells, which confirms Benda's theory that acromegaly is due to 
excessive activity of the cells in the anterior lobe of the hypophysis. 
From its association with acromegaly, the gland has been thought to 
be the "growth centre." The growth may compress the cerebral nerves, 
cavernous sinus, sympathetic nerves, bone, dura or even the brain. 
According to Sternberg, the sexes are about equally affected, and in 
50 per cent., the affection begins between twenty and thirty, in 75 
per cent, between twenty and forty, and in 14 per cent, under twenty 
years of age. 

Symptoms. — 1. Acromegaly. — Enlargement of the extremities is 
usually the first clear symptom, but is preceded by paresthesias and pains 
in the extremities, which are often extreme, and are due to expansion . 
(a) A remarkable change occurs in the face; the supraciliary ridges 
protrude, the maxillae enlarge and the nose, ears, lips, tongue, and 
chin attain massive proportions. The general contour of the face is 
hexagonal. The teeth separate, and the tongue sometimes protrudes 
beyond them. The eyes by contrast appear small. Pathologically, 
the change in the bone is hypertrophy without inflammation; there is 
increase in the vascular furrows, widening of some of the foramina 
(with narrowing of others), and some roughening of the bone and 
localized protuberances which are not osteophytes; the skull is thicker 
and larger, especially the sphenoid, supraciliary ridges, mastoid and 
occipital protuberances; the orbit may be narrowed by ethmoid 
bulging and the sinuses and sella turcica are increased. (b) The 
hands and feet are greatly enlarged; they are not deformed but are 
symmetrically hypertrophied. The fingers and toes show two types 
(Marie), the long and the thick types; they are square at their ends — 



DISEASES OF THE HYPOPHYSIS: ACROMEGALY 899 

the "spade-like fingers." The palms of the hands and soles of the 
feet become flattened. The arrays show simple hypertrophy of the 
periosteal and subperiosteal tissues, and also of the soft parts; in 
some cases the soft parts are more hyperplastic than the bones. A 
common statement in the history is that the patient "must each year 
buy a larger-sized hat, gloves, or shoes." The nails are thin and 
small. The antithesis of acromegaly is micromelia (Hutchinson), 
(c) The changes in the trunk are less conspicuous. The sternum is 
increased anteroposteriorly, and the ribs and clavicles are thickened. 
The anteroposterior dimension of the thorax is increased, the head is 
held backward, and the dorsal kyphosis is rather characteristic. The 
muscular weakness, and lean arms and legs contrast sharply with the 
first impression of strength imparted by the massive face and ex- 
tremities. The breathing is largely abdominal, (d) The skin is 
hyperplastic, and also the mucous membrane of the nose, tongue, 
pharynx and larynx. The larynx is enlarged (Marie), which may 
explain the deep, low, rough, monotonous voice. 

2. Nervous Manifestations. — (a) Symptoms of brain tumor (hypo- 
physis) are common, as headache, vertigo, mental alteration, vomiting, 
periodic loss of consciousness, bitemporal hemianopsia (early and 
frequent), optic atrophy (40 per cent.), ocular paralysis, anosmia, 
auditory disturbance, and exophthalmos. Hertel in 175 cases found 
eye symptoms in 52.5 per cent, (b) Changes in character, anxiety, 
apathy, and insomnia which deepens into terminal somnolence, are 
common; severe pains, paresthesia, acroparesthesia, and subjective 
warmth are frequent. 

3. Constitutional Symptoms.— (a) Glycosuria is more frequent than 
Hansemann's figures indicate (12 per cent.). Its relation to acro- 
megaly is uncertain, probably being a coordinate manifestation. Some- 
times polyuria occurs without glycosuria, (b) Profuse sweats are 
common, even with glycosuria; the skin is sometimes pigmented; 
obesity is common, (c) Sexual disturbance is the rule; in women 
amenorrhcea is practically constant, and is often preceded by dys- 
menorrhcea; in men impotence is not unusual; the genitalia are 
much oftener infantile than hypertrophied. (d) The heart is often 
dilated, and hypertrophied from the frequent concomitant arterio- 
sclerosis, deformed chest, and rarely from actual overgrowth (cardio- 
megaly); there may be cyanosis as the heart weakens. The vessels 
are wide and thick. Splanchnomegaly may be early observed (intes- 
tines and other viscera). In most cases the lymph nodes, particularly 
the cervical, are palpably enlarged, the tonsils, spleen, thymus, and 
sometimes the thyroid are hyperplastic. Gigantism (v.i.) occurs in 
over 20 per cent, of cases. 

Course and Prognosis. — (a) Acromegalic subjects seek advice for 
the enlargement of the extremities or tonsils, sweats, pain, eye-symp- 
toms, or polyuria; (b) remissions are common, the constitutional 
symptoms and, to a slight extent, the enlargement subside; on the 
other hand, a fitful advance may be noted, (c) The average course 



900 DISEASES OF THE DUCTLESS GLANDS 

is chronic, covering ten to twenty years, though relatively benign cases 
occur, lasting thirty or even fifty years, and acute malignant cases are 
known, which are always due to sarcoma; they may develop in a few 
weeks, and average two to four years in duration, (d) Death is 
inevitable, though it may occur from various causes; it may result 
suddenly as in brain tumor or from gradual marasmus; diabetic 
coma, intercurrent infection, cardiac insufficiency, intestinal catarrh, 
or pyelonephritis may explain the fatal issue. 

Diagnosis. — In this connection, Strumpell quotes Charcot's maxim 
that physicians in general see and diagnosticate only what they have 
seen and learned to diagnosticate; the diagnosis is made at a glance 
by one who has seen a single case ; undue regard to a single symptom, 
as the skin changes, amenorrhcea or glycosuria, may cause error, but 
the grouping of acromegalic findings is unmistakable. 

Differentiation. — 1. In the cranium progenium, the lower jaw pro- 
trudes and its teeth are directed forward; the lower jaw is hyperplastic, 
the upper jaw is hypoplastic. Cranium progenium may occur in 
acromegaly, cretinism, healthy individuals after variola, in degeneracy, 
and in idiocy. 

2. Gigantism occurs in over 20 per cent, of acromegaly (particularly 
when acromegaly develops early in life). Forty per cent, of giants 
are acromegalic (Sternberg). The interrelation of these conditions is 
incompletely understood. Gigantism proper implies symmetry of over- 
growth; there are normal "giants" and giants with acromegaly, 
leontiasis (v.i.), facial hemihypertrophy, and hereditary syphilis. 
Bassoe's report of the autopsy of the giant Wilkins covers the entire 
subject (Journal of Mental and Nervous Diseases, 1903). 

3. Diffuse hyperostosis (Starr, Putnam, Prince) occurs in the young, 
involves all the skull bones, and seldom the extremities or spine; 
exophthalmos, blindness, deafness, bilateral facial palsy, dysphagia, 
dyspncea, and other basilar symptoms are noted, which culminate 
fatally with stupor, idiocy, epileptiform convulsions, and paralysis of 
the extremities. A sub-type (leontiasis ossea, Dana, 1893) occurs in 
the form of tumor-like protuberances on the skull and other bones. 
Prince (1902) collected 20 cases from the literature. He maintains 
that it is a form of osteitis deformans. 

4. Osteitis deformans (Paget's disease, 1887) is a combined rarefying 
and hypertrophic osteitis. It begins slowly in subjects over forty 
years old, with pains and deformity of the thighs, legs, and spine; 
the legs bow widely outward and somewhat forward, the curved cer- 
vical and upper dorsal spine becomes kyphotic, the thorax narrows 
transversely and widens anteroposteriorly, the abdomen is diamond- 
shaped and crossed by a sulcus, and the head hangs forward. The 
soft parts do not hypertrophy as in acromegaly, the face is rarely 
involved, the head is larger above than below, and the arms are little 
altered. About 70 cases are on record. 

5. Hypertrophic osteoarthropathy, known since the time of Hippoc- 
rates, was especially described by Bamberger and simultaneously by 



DISEASES OF THE HYPOPHYSIS; ACROMEGALY 901 

Marie, in 1889. The ends of the fingers and perhaps the toes become 
clubbed or "drumstick" in appearance. While the nails are thin and 
small in acromegaly, in hypertrophic osteoarthropathy, they are large, 
thick, wide and curved downward. The alteration typically involves 
the terminal phalanges, but also in severe cases the ends of the ulna, 
radius, tibia and fibula. The pathology is a toxsemic, chronic peri- 
ostitis, with hypertrophy and osteophytic growth. The most common 
cause is chronic lung disease (chronic phthisis, bronchiectasis, emphy- 
sema, or fibrosis), whence Marie's name of osteoarthropathie hypertro- 
phiante pneumonique; it may develop in congenital heart disease or 
aneurysm, or, much less frequently, in icterus, gastric dilatation, 
syphilis, cystitis, or various infections. Adult males are most often 
affected. 

The treatment of acromegaly is merely symptomatic. Extract of the 
hypophysis has been given, and in a few cases with temporary success. 



SECTION VIII. 



CONSTITUTIONAL DISEASES 



(A). DIABETES MELLITUS. 

Definition. — An independent disease of metabolism characterized 
(a) by a permanent lessened capacity of the organs fixing, storing and 
consuming grape sugar; (b) by excess of sugar in the blood (hyper- 
glyccemia), resulting in (c) grape sugar in the urine (glycosuria) ; (d) 
causal changes in the pancreas. (The term mellituria includes the 
presence of all kinds of sugar in the urine.) 

Willis (1622-75) first differentiated between diabetes mellitus and 
diabetes insipidus, and Dobson (1774), of Liverpool, fully described 
the clinical symptoms. 

The liver, the reservoir for carbohydrates, may contain even 14 
per cent, of glycogen. It collects carbohydrates from the portal vein, 
stores them as glycogen, and again imparts them to the blood as 
grape sugar, for use in the tissues. The muscles also manufacture 
glycogen from the grape sugar of the blood, and are more tenacious 
of it than is the liver. Glycogen may also be produced from the album- 
inates. When there is a temporary carbohydrate shortage, the reserve 
store of glycogen is drawn upon. Fat is converted in the liver into 
sugar, when neither the carbohydrates or the albuminates suffice to 
maintain the normal proportion of sugar in the blood. The fate of 
carbohydrates when ingested in excess is: (a) glycogen storage (up 
to 10 ounces — 300 grams); (b) conversion into fat; (c) alimentary 
glycosuria from hyperglycemia, when the sugar in the arterial blood 
exceeds 0.2 per cent.; this is known as "alimentary glycosuria," 
which is physiological, wholly distinct from diabetes mellitus, and 
occurs when the blood-sugar exceeds the assimilation limit. The 

903 



904 CONSTITUTIONAL DISEASES 

test for alimentary glycosuria consists of giving 3 ounces (100 gms.) of 
grape sugar, after a light breakfast of bread and coffee. If more than 
1 per cent, of sugar appears in the urine, or if 2 or 3 per cent, of the 
entire amount administered is found, it is indicative of diabetes rather 
than of glycosuria. Most sugar absorbed goes to the liver, but some 
absorbed by the lymphatics appears in the urine, whence its presence 
is not necessarily a sign of diabetes; in liver cirrhosis, sugar may 
reach the blood with the collateral circulation. Traces of sugar 
(0.01 to 0.02 per cent.) are normally present in the urine, but are not 
detected by the usual tests, whence healthy urine is regarded as free 
of sugar. 

Etiology. — 1. The pancreas (q.v.) has long been considered an etio- 
logical factor in diabetes. Recently Opie discovered atrophic changes 
in the cells of the islands of Langerhans ; they are determined only by 
microscopic examination. These cells are thought to produce an 
internal secretion, concerned in breaking up sugar in the tissues and 
muscles. This internal secretion from Langerhans' islands, is wholly 
distinct from the external secretion of the pancreatic juice voided 
into the intestine. Lepine some years ago spoke of a "glycolytic 
ferment," which entered the^ blood from the pancreas and broke up 
the sugar molecules; in diabetes resulting from the absence of the 
ferment, the sugar is not broken down. This ingenious argument has 
received much experimental corroboration, since (a) total pancreatic 
extirpation in animals and man produces glycosuria; (b) after partial 
extirpation and suture of the remaining portion to the abdominal 
wall, diabetes fails to appear, but develops if this portion is later 
removed; (c) when about a tenth part is left, a mild form of diabetes 
ensues, and glycosuria occurs only after the ingestion of carbohydrates; 
(d) subsequent destruction of the remaining portion of the gland 
produces a severe form; (e) when more than one-tenth of the func- 
tionating gland is left behind no diabetes ordinarily results; (/) diabetes 
does not occur in simple ligature of the pancreatic duct, excluding the 
juice from the intestine, nor when the fluid escapes through a cutaneous 
fistula, whence the argument that there is an internal secretion, (g) 
Cohnheim's experiments (1903) suggest that a ferment or pro-enzyme 
secreted by the pancreas, joins another ferment secreted by the muscles, 
and that the united ferments break down the sugar molecules to pro- 
duce heat and energy. In 167 patients, Thoinot and Delamare found 
"Langerhans' insufficiency" in 80 per cent., and chiefly in "lean 
diabetics." 

2. There is a neurogenous diabetes, the relations of which (if there are 
any) to the pancreas are wholly obscure. This and the following type 
might be considered as symptomatic diabetes. Nervous diseases, as 
Claude Bernard's well known puncture of the fourth ventricle, may 
possibly alter the circulation in the liver. Among them are apoplexy, 
tabes, brain tumors (particularly those located near the base), general 
paralysis, multiple sclerosis, meningitis, syphilis, softening of the brain, 
diseases of the cord, vagus and sympathetic system, trauma, traumatic 



DIABETES MELLITUS 905 

neurosis, paralysis agitans, mental diseases, Basedow's disease, and 
acromegaly. Hoffman distinguishes between (a) neurogenous dia- 
betes, which occurs chiefly in men, with no tendency to furuncles, 
carbuncles or cataract, with no connection with gout, and which passes 
away if the brain affection is curable, and then always in a compara- 
tively short time, though in some cases it causes death within two 
years; and (b) diabetes of the obese, which occurs as frequently in 
women as in men, often produces carbuncles, is often connected 
with gout, and is very chronic, often lasting ten or twenty years. 

3. Obesity may be a cause; according to von Noorden, " There are 
(a) cases in which the consumption of sugar and its conversion into 
fat are simultaneously restricted — glycosuria which varies in severity, 
and in degree of emaciation (ordinary diabetes); (b) cases in which 
only the consumption of sugar, and not its conversion into fat is inter- 
fered with — obesity without glycosuria (masked diabetes); these pass 
readily at a later period into (c) cases in which the consumption of 
sugar is restricted, and the collecting of carbohydrates in the fatty 
tissues is also more or less interfered with — obesity with consecutive 
glycosuria (ordinary diabetes of the adipose)." 

4. Gout, arteriosclerosis, various liver lesions (cirrhosis), and possibly 
acute infections, have apparent though obscure relations with diabetes. 
Adrenalin may produce glycosuria (Blum and Herter). Renal diabetes 
(glycosuria without an excessive amount of sugar in the blood) may 
occasionally develop in nephritis, renal hemorrhage, chyluria, and from 
administration of the glucoside, phloridzin. Lactosuria may occur in 
late pregnancy, the puerperium and nurslings; von Noorden's hypoth- 
esis is that in the "puerperal state the capacity of the tissues for 
breaking up milk-sugar is diminished, an instance of adaptation to 
an end in that the cells of the mother refuse a material which is pre- 
eminently suited to the nutritive wants of the nursling/' 

5. Predisposing factors are (a) sex; men (3:2) are especially subject 
to diabetes; (b) age; though it occurs at any age, its frequency is as 
follows: In persons from thirty to forty years, 18 per cent.; forty to 
fifty years, 25 per cent.; fifty to sixty years, 26 to 30 per cent.; in 
Stern's collection of 117 infantile cases, one was apparently congenital, 
(c) Heredity. A family history of obesity, consanguinity, neuropathic 
taint (20 per cent.), or gout is especially significant; cases are reported 
in which the grandfather was diabetic, the son gouty, and the grandson 
again diabetic (hereditary alternating diabetes), (d) Race. Diabetes 
is comparatively rare in the colored race, and is especially common in 
Jews. It is rather less common in America than in Europe, (e) 
Occupation. Diabetes is more often seen in private than in hospital 
practice. Wealth and culture increase ten-fold the predisposition to 
diabetes (von Noorden). It is frequently found in scientists, lawyers, 
musicians, poets, teachers, statesmen, merchants, speculators, and in 
those leading a luxurious or self-indulgent existence with sedentary 
habits ; it also results from overwork, excitement, over-eating and over- 
drinking. Diabetes is apparently increasing in frequency. 



906 CONSTITUTIONAL DISEASES 

Symptoms. — 1. The Urine. — Glycosuria. — Sugar in the urine is 
the leading symptom of diabetes. A daily excretion of 1 to 3 drams 
(5 to 12 grams), is not uncommon; the maximum amount recorded is 
1,500 gm. ; the largest quantity of sugar is voided late in the morning 
or after 6 p.m. A percentage of from 1 to 4 is not uncommon, 8 or 
9 per cent, is rare, and the maximum is 20 per cent, (personal obser- 
vation). The estimation of a diabetic's capacity to consume sugar, 
suggested simultaneously by Seegen and Traube is as follows : Accord- 
ingly as the urine, after a diet absolutely free from carbohydrates, is 
free from sugar or not, a distinction is made between (a) mild and (b) 
severe cases of glycosuria, (a) Mild glycosuria is characterized by 
the urine becoming sugar-free within a few days after carbohydrates 
are withdrawn, and by sugar reappearing when carbohydrates are 
again ingested. The test diet consists of ham, eggs, roast beef, cucum- 
ber with vinegar, olive-oil, and salt and pepper; brandy with Appolin- 
aris*water; coffee without milk or sugar; clear bouillon ; butter, green 
salad, green vegetables, and sardines; this diet is free from carbo- 
hydrates. With increasing additions of starch, sugar at some time 
is again voided, i.e., the limit of tolerance or of assimilation is reached. 
(6) Severe glycosuria is characterized by continued excretion of sugar, 
in spite of the withholding for days of all carbohydrates from the diet, 
and signifies (i) that even those carbohydrates which are slowly formed 
from the albumin are not wholly consumed; (ii) that the functions 
of glycogen storage, and (hi) of splitting up of sugar in the tissues are 
seriously affected; of this type there are many degrees. Fat and 
alcohol never increase the severity of glycosuria. Muscular exercise 
and massage usually decrease it. It is often increased by psychic 
disturbances and may be suspended or lessened during an acute 
intercurrent infection, especially in typhoid; chronic diseases with 
fever, especially pulmonary tuberculosis, have less influence. It is 
reduced or absent in the final stages of diabetes, and may be absent 
in diabetic coma. Glycosuria very often disappears when granular 
atrophy of the kidney develops (Frerichs, Stokvis, Furbringer); the 
diabetes is then cured in some unknown way. Gouty diabetics as a 
rule pass no sugar during an attack of gout (diabetes alternans). 

Tests for Sugar. — (a) For Fehling's test, two solutions are kept 
separate; one contains copper sulphate, 34.64 gm. in 500 c.c. of water, 
and the other, sodium and potassium tartrate 173 gm., and sodium 
hydrate 125 gm. in 500 c.c. of water. Equal parts of these solutions 
are heated, but not boiled, and the urine is added drop by drop. 
The volume of urine should never exceed that of the solutions. Re- 
duction of the blue copper solution to the yellow-red suboxide of 
copper occurs when sugar (its aldehyd group) is present. Chloral, 
phenacetin, chloroform, formalin, morphine, uroleukinic, and homo- 
gentisinic acids (the probable causes of alkaptonuria), glycuronic acid, 
cascara, rhubarb, and salicylates, may also reduce Fehling's solution, 
particularly after boiling. In doubtful cases, or as corroborative tests, 
(b) the fermentation test may be used; yeast is shaken thoroughly 



PLATE XV, 




Crystals of Pbienyl-glueosazone. (Musser.) 

(Oc. 4, Obj. D.) Drawn by J. D. Z. Chase. 



DIABETES MELLITUS 907 

with a quantity of urine, the air allowed to bubble up, and the mixture 
placed in a saccharometer, — a tube closed at the top, and graduated 
for estimation of percentages. The sugar, fermenting, is measured 
by the amount of carbon dioxide formed. A control test should be 
made, (c) The polarization test, showing dextro-rotary reaction, may 
be employed, (d) The very delicate and reliable phenylhydrazin test 
of E. Fischer may be used. Cipollina's method is the simplest: 5 
minims of pure phenylhydrazin, eight drops (0.5 c.c.) of glacial acetic 
acid, and a dram (4 c.c.) of urine in a test-tube are gently boiled for 
one minute with frequent agitation. Four or five drops of sodium 
hydrate solution are added, the mixture is boiled again, and allowed 
to cool; in a few minutes (to a half an hour) yellow rosettes of 
phenylglucosazon precipitate; maltose and certain pentoses, the crystals 
of which melt at different degrees, may alone cause error. Plate XV. 
Quantity of Urine and Specific Gravity. — The urine is almost 
always acid even after fermentation (lactic acid), and has a sweet 
taste. As a general rule the quantity of urine secreted during the 
night is less than that secreted in the day-time; this is an important 
point because in other polyurias frequently § to f of the entire amount 
of urine is secreted during the night (Lecorche and Quincke). A 
secretion of ten quarts is not rare. The largest amounts recorded are 
16, 17 or 28 quarts in a day. Higher figures suggest simulation, 
patients having been known to add sugar to the urine. Pollakiuria 
(frequency of urination) is common. The urine is pale. If dark and 
if uratic deposits are present, the prognosis is good (Seegen and Pavy). 
Foam often remains long on its surface and the sediment is very 
scarce or is absent. Prout considered that the onset of diabetes began 
at the time the urine ceased having a turbid, uratic deposit. An in- 
crease in the amount of sugar usually brings an increase in the amount 
of urine, but ordinarily the amount of urine rises less rapidly than 
does that of the sugar. The specific gravity is higher, the greater 
the amount of urine secreted. 

Amount in 
liters or quarts. Specific gravity. Sugar. 

1 . 5 to 2.5 1 . 025 to 1 . 030 2 to 3% 

2.5 to 4 1.030 to 1.036 3 to 5% 

4 to 6 1.032 to 1.046 4 to 7% 

6 to 10 1.036 to 1.046 6 to 9% 

Two or three per cent, of sugar may cause no change in specific 
gravity. The average is 1,030-40, it is rarely more than 1,050, and 
the highest record is 1,074; very high specific gravity suggests fraud; 
the lowest records are 1,002 and 1,008. If under the influence of 
meat diet, the urine becomes entirely or nearly free from sugar, the 
quantity approaches normal. The specific gravity remains high 
because the urine is rich in meat end-products. There is no absolute 
parallelism between the percentage of sugar and the specific gravity; 
(a) glycosuria is often preceded by premonitory polyuria, (b) Though 



908 CONSTITUTIONAL DISEASES 

diabetes may be cured, polyuria may persist without glycosuria; this 
may be caused by the habit of drinking large quantities of water, (c) 
There are some cases in which though there is a large percentage 
of sugar, only a pint or a pint and a half (500 to 800 c.c.) of urine is 
secreted; this was first described by Peter Frank a century ago as 
"diabetes decipiens." Crystals of sugar may be seen on the shoes, 
clothing, or in the vessel. 

Nitrogenous Constituents of the Urine. — Diabetic patients 
usually excrete considerable urea; 2 ounces (50 to 60 gm.) are not in- 
frequent, and over 5 ounces (163 gm.) have been noted; larger figures 
are reached in no other disease; it is occasioned by the abundant 
ingestion of proteids, and possibly by fermentation of the tissue 
albumins; the condition is pathological when the amount of nitrogen 
in the urine exceeds that in the food. Naunyn and von Mehring deny 
that there is an increase in the urea save in severe and exceptional 
cases. 

Ammonium, normally 8 to 15 grains (0.5 to 1 gm..) per diem, may 
increase to 20 or 180 grains, although the highest figures are seen 
exclusively in diabetic coma. The organism excretes increased amounts 
of ammonia in order to neutralize pathological acids (acidosis). The 
diabetic diet is acid; phosphoric acid forms from the ingested meat, 
and much sulphuric acid is produced by oxydation of sulphur in the 
albumin molecule. The quantity of creatinin may reach 20 to 30 
grains (1.3 to 2 gm.) per diem, because of the diet, and tissue waste. 
The amount of uric acid is nearly normal. 

Albuminuria is found in from 30 to 40 per cent, of cases; it is 
almost always slight, and is due (a) to cystitis, pyelitis, intercurrent 
diseases as gangrene or infection, pulmonary tuberculosis, and in some 
cases without relation to diabetes as in the arteriosclerotic and gouty 
types of diabetes, to liver cirrhosis, etc.; (b) to diabetes in nervous 
individuals, and (c) to circulatory disturbances; (d) in uncomplicated 
cases of diabetes it may be due to the action of the sugar, /?-oxybutyric 
and other acids and toxins on the kidneys. Albuminuria is a frequent 
forerunner of diabetic coma, either as a coordinate manifestation or a 
determining factor (decreased renal permeability with retention in 
the blood of toxins). Diabetes may develop into chronic interstitial 
nephritis, and the sugar then disappears. 

Non-nitrogenous organic substances. Lipuria has been observed. 
Acetone, aceto-acetic acid and beta-oxybutyric acid are most frequent; 
they may be derivatives of albumin or of fat. Beta-oxybutyric acid 
is absent in diabetics who are in good physical condition, and not infre- 
quently also in those who are suffering from marked loss of albumin. 
The urine may be odorless, or may smell like chloroform, fruit or 
wine. Sometimes the daily amount excreted is only a few grains; 
at other times it reaches 2 to even 7 ounces (50 or 226 grams). Its 
abnormal excretion once begun, is uninterrupted, sometimes lasts 
years, and shows a constant tendency to increase. It is of the gravest 
prognostic significance because in most cases, at the end of days, 



DIABETES MELLITUS 909 

weeks or months, fatal diabetic coma develops. An excretion of more 
than an ounce indicates imminent coma. Acidosis is most accurately 
estimated by the output of ammonium; according to Magnus Levy, 
2 gm. of ammonium correspond to 6 gm. of /?-oxybutyric acid, 5 gm. to 
20 gm., and 8 gm. to 36 or 40 gm. /?-oxybutyric acid is thought by 
some to be the parent substance of acetone or diacetic acid. Acetone 
and diacetone are present in the urine in diabetes, fevers, cancer, in- 
anition or auto-intoxications, and indicate malnutrition. When the 
amount of acetone progressively rises from 15 grains upward, the 
outlook is unfavorable. It is not proven that the acetones cause 
coma, but they at least accompany acidosis. They impart a fruity 
or wine-like odor to the urine and breath. Denniges' test for acetone 
(quoted from Simon's Clinical Diagnosis) is as follows: 20 grams 
of concentrated sulphuric acid are poured into 100 c.c. of distilled 
water, when 5 grams of freshly prepared yellow mercuric oxide are 
added. The mixture is allowed to stand for twenty-four hours. This 
reagent is added to 3 c.c. of urine, drop by drop, until the precipitate 
thus formed no longer disappears on stirring. When this point is 
reached a few more drops are added. After two to three minutes 
the precipitate is filtered off. The clear filtrate is further treated 
with about 2 c.c. of the reagent, and 3 to 4 c.c. of a 30 per cent, solu- 
tion of sulphuric acid, and placed in a vessel with boiling water. 
In the presence of an abundant amount of acetone a copious white 
precipitate forms immediately; while in the presence of traces only (less 
than 1 : 50,000), a slight cloud develops on standing for several minutes* 
The precipitate is almost entirely soluble in an excess of hydrochloric 
acid. If albumin is present, the urine becomes turbid at once when 
the reagent is added. In that case the test is continued as described, 
attention being directed to the coarser precipitate which occurs later. 
To such urines large amounts of the reagent must be added, the idea 
being to precipitate everything that can be precipitated with the 
reagent, before heating. Oppenheimer claims that it is a delicate 
test, and gives well-pronounced reaction with a dilution of 1 : 20,000. 

Gerhardt's test for diacetone is as follows: a dram of urine is 
treated with a strong solution of ferric chloride added drop by drop. 
A precipitate of phosphates is filtered off, and more of the iron solution 
is added to the filtrate. If a bordeaux-red color now appears, another 
portion of the urine is boiled, and similarly treated. If in the second 
test no reaction is obtained, a third portion of the urine is treated 
with sulphuric acid and extracted with ether. A positive reaction, 
when the ethereal extract is tested with ferric chloride, the color dis- 
appearing upon standing for twenty-four to forty-eight hours, indicates 
diacetic acid, particularly if the urine is rich in acetone. 

Mineral Constituents. — Sodium chloride, sulphuric and phosphoric 
acids, and the ethereal phosphates are abundant; they are caused 
by the increased amount of food ingested. The oxalates are increased 
in mild cases. Much lime is excreted, which suggests osseous waste. 



910 CONSTITUTIONAL DISEASES 

Pneumaturia. — The butyric acid bacillus, the Bacillus coli, yeast 
fungus and other bacteria may cause fermentation in the bladder, 
producing carbon dioxide, hydrogen, and methane gas. 

2. Direct Consequences of the Glycosuria and Polyuria. — (a) The 
exaggerated thirst (polydipsia) is always secondary to the polyuria. 
(b) Nutrition is affected. Much sugar is lost to the tissues; two 
quarts of urine with 5 per cent, of sugar produces loss of 400 calories, 
one^seventh of the total. Therefore the nutritive requirements are 
great, the appetite is excessive (polyphagia) and in severe cases emacia- 
tion and fatigue are pronounced. The loss of sugar must be met by 
increase in albumin and fat. Increase in weight may follow reduction 
in the sugar. The temperature in uncomplicated cases is subnormal 
from inanition. 

3. Complications. — Complications and other symptoms result from 
various causes: (a) the sugar in the blood, (b) impaired nutrition and 
lowered physiological resistance; both conditions predispose to (c) 
infection, particularly by the bacillus tuberculosis, (d) poisoning 
(acidosis), and other ill-understood conditions, which 'promote degen- 
erations and toxsemia. 

1. Nervous. — (a) Intellectual depression, insomnia, headache and 
neurasthenic symptoms are common, though psychoses are less fre- 
quent. In rare instances focal symptoms may develop (as in uraemia) 
without anatomical findings. Brain symptoms may result from coin- 
cident syphilis, arteriosclerosis, etc. (b) Diabetic coma occurs in 20 
per cent, and causes about half the deaths in diabetes; it is most fre- 
quent in youth, and in acute and severe types; Naunyn holds that 
it is favored by a strict antidiabetic diet. All cases of coma which 
develop in diabetes are not diabetic; patients may succumb (i) to 
cerebral apoplexy, tuberculosis, embolism, thrombosis, sepsis, or 
uraemia, (ii) to heart failure, which may cause sudden death, or coma 
with death after a short time or (iii) diabetic coma proper, which is 
probably due to toxaemia (acidosis), and closely resembles experi- 
mental acid poisoning. Most writers believe that /?-oxybutyric acid 
is causal, though in three of the author's cases it was not present 
in the urine (Long). Coma is imminent when the daily output of 
ammonium exceeds 45 grains (3 gm.), for this measures the acidosis. 
It may occur suddenly without obvious cause, or may follow severe 
exertion, excesses, excitement or gastro-intestinal disorders. In some 
cases there are prodromal headache vertigo, stupor, restless anxiety or 
symptoms resembling those of acute alcoholism. The pupils are 
dilated, the reflexes abolished, the pulse is small, and averages 100 
to 120, and the temperature is usually subnormal. Convulsions are 
most uncommon. The breath has the wine-like acetone odor. The 
breathing is characteristic; inspiration is deep, long-drawn and ener- 
getic and expiration is short and slightly sighing; in this, KussmauVs 
dyspn&a, the inspiratory energy contrasts strongly with the general 
bodily weakness; respiration may be normal in rate, but is generally 
somewhat accelerated; there is no stridor, nor, at the onset, any 



DIABETES MELLITUS 911 

cyanosis. The urine is generally albuminous and almost always con- 
tains small granular casts (Kiilz and Adelhof); the addition of a few 
drops of ferric chloride gives the Burgundy wine color; sugar is 
present, though it may occasionally disappear as the coma develops. 
Partial consciousness may return, but, with few exceptions, death 
occurs within a few hours to two days, with subnormal temperature, 
slowed respiration and cardiac weakness. The autopsy reveals no 
constant brain changes, (c) Degeneration (toxemic) in the posterior 
columns of the cord may develop, (d) The peripheral nerves may be 
affected. Neuralgia is common and may indicate incipient neuritis, 
or may appear and disappear, varying with the amount of sugar in 
the blood and urine. It is often an early symptom; it may be uni- 
lateral or more often bilateral, most frequently affects the sciatic 
nerves, and is not uncommonly a most obstinate and recurrent symp- 
tom. Neuritis, as a general rule, occurs in the severe forms of diabetes, 
and in its later stages. It may be manifested only by obstinate neu- 
ralgia, painful paresthesia in the legs, muscular cramps or in 30 to 
50 per cent, of diabetics, decrease or abolition of the patellar reflexes. 
Neuritis may involve the cranial nerves, mostly the abducens, then 
the oculomotor, hypoglossus, spinal accessory and facial, or with 
greater frequency the spinal nerves ; the lower are affected more 
often than the upper extremities, and, like diabetic neuralgia, bilateral 
involvement of the crural or sciatic nerves is the most common type. 
Neuritis may be single or multiple (polyneuritis). Its symptoms are 
those of neuritis or polyneuritis (q.v.), as paralysis, altered sensation, 
abolished reflexes, reaction of degeneration and trophic disturbances, 
as falling of the hair and nails, glossy skin, and perhaps also herpes 
or perforating ulcer of the foot (mal perforant). In severe cases tabes 
is simulated, pseudotabes diabetica (see Multiple Neueitis). (e) The 
special senses may be involved. Retinal diseases occur under three 
forms: (i) albuminuric retinitis, accompanying contracted kidney; 
(ii) retinitis centralis punctata with characteristic small, shining central 
spots, usually with hemorrhagic points, and always bilateral; (iii) the 
ordinary hemorrhagic type (see Plate V, Fig. 1). Retinitis occurred in 
19 per cent, of Galezowski's 114 cases. Neuritis, neuroretinitis and 
retrobulbar neuritis with consecutive atrophy are progressive, and occur 
more frequently in severe than in mild cases, sometimes as early, 
sometimes as late, complications. Twenty per cent, of diabetics with 
retinitis die within one year, and 60 per- cent, live over two years 
(Nettleship). 

Amblyopia and amaurosis are complications of early diabetes, and 
often first induce the patient to seek medical advice. Paralysis of the 
ocular muscles occurs in 7 per cent, of cases; accommodation paralysis 
is the most frequent type, and then that of the external rectus; the 
most probable cause is neuritis; Mauthner assumes that there is a 
nuclear hemorrhage. Cataract occurs in 4 per cent, of cases. Other 
ocular changes are rare. Aural complications include external fur- 



912 CONSTITUTIONAL DISEASES 

uncles and otitis media, which has a tendency to hemorrhage and 
diffusion, as mastoiditis. 

2. Circulatory. — (a) The blood may become somewhat concen- 
trated, for much water is required to eliminate the sugar; the amount 
of sugar (normally 0.1 to 0.15 per cent.) is increased in diabetes to 
0.3 or 0.5 per cent. Fat in the blood (lipsemia) is a frequent finding; 
what appears to be fat is sometimes albumin (Futcher) or cholestearin 
in combination with fatty acids; Frazer in one case found 14 per 
cent, of fat. Bremer's test is based on changes in the hsemoglobin; 
thick smears ofblood are made on a slide, which is heated and treated 
with 1 per cent, congo red solution for two minutes; diabetic blood 
will not stain, but the control slide of normal blood stains; this reac- 
tion, according to Bremer, often results during remissions in the 
glycosuria and in the preglycosuric stage; it sometimes occurs in other 
conditions, as Hodgkin's disease. Williamson's test is based on the 
fact that diabetic blood decolorizes a weak alkaline solution of methyl 
blue. It is as follows : 20 c.c. of blood, 40 c.c. of distilled water, and 
1 c.c. of 1 to 6,000 aqueous solution of methylene blue are added to 
40 c.c. of liquor potassse, and are placed in test-tubes in a beaker 
of water, which is boiled for four minutes; the blue color disappears. 
The alkalescence of the blood, which is reduced in various conditions 
of inanition, is greatly lessened in diabetes, particularly when /?-oxy- 
butyric acid engages the ammonium and other salts and when coma 
develops. (6) The arteries are frequently sclerosed in diabetes. 
Arteriosclerosis causes many common symptoms, as cardiac hyper- 
trophy or dilatation, angina pectoris, cardiac asthma, hemiplegia, 
albuminuria, senile gangrene, and intermittent claudication. (c) 
The heart may be altered in various ways (v.s.). Hypertrophy occurs 
in about 10 per cent, and is less ominous than atrophy, which occurs 
in uncomplicated diabetes of the young. Heart-failure may occur 
after moderate exercise, or may develop precipitately, ending in coma 
or asphyxia and correctly separated by Frerichs from genuine diabetic 
coma. Von Noorden observed five instances of sudden death in 140 
fatal cases. "Functional heart symptoms " occur in 10 per cent, of 
cases. The pulse is usually accelerated, and its tension is elevated. 
Cardiac or renal dropsy is uncommon in diabetes. 

3. Respiratory. — (a) Tuberculosis is most frequent in the poor 
classes, and in the young, but much less so in older, obese and gouty 
subjects ; about 25 per cent, of diabetics contract tuberculosis. Haemop- 
tysis is very rare (Seegen and Leyden); the sputum is abundant; 
it is usually stated that the tubercle bacilli are scant or absent; in 
the secondary necrosis, to which all diabetic tissues are prone, the 
marked clinical and pathological lung-findings may sharply contrast 
with the small number of tubercle bacilli found in the sputum. The 
course is rapidly fatal. (6) Gangrene is much less common than 
tuberculosis. Fever, pulmonary hemorrhage, and purulent sputum 
are common. Foetor is less conspicuous than in other forms of pul- 



DIABETES MELLITUS 913 

monary gangrene, (c) Intercurrent pneumonia may develop, and is 
usually fatal. 

4. Digestive. — (a) The mouth is generally dry and acid (from 
decomposition of sugar); the saliva is scanty and poor in ferment; 
stomatitis is common, and the growth of aphtha? is promoted by the 
acid reaction of the mouth, though it is preventable by cleanliness. 
The teeth may decay from alveolar periostitis or drop out from tropho- 
neurotic changes, (b) The stomach is affected with remarkable in fre- 
quency, considering the oral findings, and the polyphagia. Marked 
anorexia is uncommon, though the patient may refuse fatty and 
nitrogenous food. The stomach is usually dilated, (c) The bowels 
are generally costive. Schmitz claims that obstinate constipation pre- 
disposes to coma, though in the author's experience, most diabetics 
are constipated. Intestinal or gastro-intestinal catarrh sometimes seems 
to precipitate coma, but it may be merely an associated symptom. 
(d) The liver is usually enlarged (hyperemia and fatty degeneration), 
and sometimes tender. Gall-stones are concomitants in 10 per cent, 
of cases, according to Bouchard, but Naunyn is correct in denying 
that they have any intrinsic relationship to diabetes. French authors 
(Hanot and Chauffard) have described a pigmentary cirrhosis in 
diabetes (diabete bronze), which has already been referred to under 
liver cirrhosis, and chronic pancreatitis; this syndrome probably 
develops in the following sequence: (i) haemolysis, (ii) pigment deposit 
in the liver, pancreas, and skin from the altered blood (haemochroma- 
tosis), (iii) chronic interstitial inflammation, chronic hepatic cirrhosis, 
and (iv) chronic pancreatitis, causing diabetes, (e) Pancreatic symp- 
toms are few, because the external pancreatic secretion is essentially 
normal, and only the internal glycolytic secretion is affected. 

5. Genitourinary. — (a) Albuminuria may be present (see Urine). 
The kidneys are frequently hypertrophied and hyperaemic; various 
degenerations may be noted, including Ehrlich's glycogenic degener- 
ation. Interstitial nephritis may follow and replace diabetes, chiefly 
in gouty and corpulent individuals. (6) Cystitis is not rare; the urine 
may actually ferment in the bladder, just as it readily decomposes 
in the urinal; this may lead to pyelonephritis or pneumaturia (v.s.). 
Cystitis may cause temporary disappearance of the glycosuria, (c) 
In the female, menstruation may be disturbed or suspended. The 
sexual inclination is usually lessened in severe cases, but may be 
increased in mild cases from genital pruritus (v.i.). Conception may 
occur even in advanced cases, but in 33 per cent, there is spontaneous 
abortion or premature delivery. In severe diabetes interruption of 
pregnancy is indicated, but care must be taken that diabetes gravi- 
darum is not confused with lactosuria; the maternal danger in unin- 
terrupted pregnancy is great, from exacerbation of the disease, coma, 
collapse and infection, though Stengel has recently concluded that the 
danger is overdrawn. Fungi readily develop about the labia and 
vagina; this is promoted by lessened general resistance and local 
contact with the saccharine urine. Aphthae, leptothrix and other 

58 



914 CONSTITUTIONAL DISEASES 

parasitic deposits are frequent, particularly in careless subjects; pru- 
ritus pudendorum, vulvitis, vaginitis, urethritis (which may simulate 
gonorrhoea), furunculosis and even gangrene may develop, (d) In 
the male, the sexual appetite may be increased early in the disease 
but later is replaced by impotence, which is probably due to spinal 
degeneration. Phimosis, balanitis, small erosions near the urethra, 
urethritis, itching at the meatus causing tenesmus, curious nodes in 
the corpora cavernosa, furuncles and necrosis may first engage the 
physician's attention. Genital symptoms in men are less conspicuous 
than in women. 

6. Cutaneous. — The skin is dry, rather harsh and itches when 
there is much polyuria and emaciation. Sugar is said to be present 
when the patient sweats. Itching is caused by toxaemia irritating the 
cutaneous nerves, as in ursemic and cholsemic pruritus. Skin eruptions 
include pityriasis tabesentium, urticaria, erythema, eczema, bullae, 
acne, purpura and herpes. Infection is favored by reduced physio- 
logical resistance and possibly by hyperglycaemia; furunculosis (10 to 
25 per cent.) is due largely to the staphylococcus, and may initiate 
lymphangitis, phlegmon or gangrene; erysipelas is promoted by re- 
duced general and local resistance. Gangrene is most frequent in 
late or middle life, and in mild cases; it usually begins on the toes 
and extends upward, either as dry or moist gangrene; it is said to 
result from obliterating endarteritis, but in the writer's experience, 
occurs three times less frequently than the ordinary plaque-like ather- 
oma. Unfortunately gangrene is usually progressive. Wounds in 
diabetics heal better than in pre-antiseptic times, but delayed healing, 
infection, and gangrene are still frequent. Enlargement of the lym- 
phatic glands is seldom absent in severe, progressive forms with ema- 
ciation ; the glands are hard, painless, and probably secondary to skin 
infection or irritation. 

Course and Prognosis. — The onset may be acute or chronic, and 
the course may be short (covering weeks) or protracted and remittent 
(covering twenty years or more). Various complications modify the 
duration and outcome. Von Noorden's summary of the general 
prognostic signs covers the ground completely. Favorable signs are: 
(a) onset late in life; (b) long duration prior to the time of obser- 
vation, with no grave complications nor any considerable emaciation; 
(c) traumatic causation; (d) syphilitic origin; (e) the occurrence 
invariably of mild forms of diabetes in the family of the patient; (/) 
precedent and co-existent obesity; (g) co-existent uric acid diathesis; 
(h) slight glycosuria and tolerance of moderate amounts of carbo- 
hydrates; (i) marked oscillations and increasing tolerance of carbo- 
hydrates; (j) circumstances which permit of dietetic and general 
hygienic prescriptions. Unfavorable prognostics are: (a) onset in 
early life, especially in childhood; (b) great loss of strength, despite 
a brief duration of the diabetes; (c) a history of severe forms in the 
family; (d) early appearance of grave secondary diseases and com- 
plications; (e) a high degree of glycosuria, with complete intolerance 



DIABETES MELLITUS 915 

of carbohydrates; (/) excretion of /?-oxybutyric acid; coma; (g) poor 
circumstances which render impossible the dietetic treatment, or the 
avoidance of bodily and mental overwork. 

Diagnosis. — The diagnosis is certain only when the urine in every 
case is examined as a routine procedure, because only then can the 
lighter cases, which are amenable to treatment, be discovered. In 
many cases the thirst, polyuria, emaciation, itching, and the compli- 
cations per se are suggestive. Pentosuria; 16 familial or hereditary 
cases are recorded. Pentose reduces Fehling's solution, even after 
fermentation of the urine. Bial's test is made as follows: a small 
amount of the following solution, orcin 1 gm., liq. ferri chloridi 25 
drops, and 30 per cent, hydrochloric acid in 500 c.c. of water, is heated 
to boiling, and added to the urine which turns green if pentose is 
present. 

Treatment. — 1. Diet. — Regulation of diet, dating from Rollo one 
century ago, is the most essential point. The carbohydrates normally 
supply nearly half the bodily requirements for food and energy. The 
diabetic loses a large part by their escape through the kidneys. Further- 
more, their ingestion implies a waste of digestive energy, an irritation 
of the tissues by the unused sugar, and a growing decrease of the 
tolerance of the tissues for them. A man weighing 70 kilograms 
(150 lbs.) requires a diet representing 2,500 calories, i.e., roughly 35 
calories for each kilogram. The dietary must therefore regard not 
merely the glycosuria, but the maintenance of body-weight and energy. 
It is useless to suppress the symptom, glycosuria, when the patient 
emaciates. The object in view is to limit the carbohydrates, and 
replace them with albumin and fat. Naunyn and Weintraud have 
proven that exclusion of carbohydrates for some weeks increases the 
tolerance for carbohydrates taken afterward; i.e., the "sugar-con- 
suming function" is rested and in part restored. 

General Outlines of Dietary. — Explicit written directions 
should be given to each patient. All diabetics may eat the following 
foods: meat, the muscular parts of beef, veal, mutton, and game, and 
the tongue, lung, heart, brain, marrow, and sweet-breads; also fatty 
livers, which contain but little glycogen; meat peptones, somatose 
and kindred preparations, gelatin, and meat jellies; fish, caviar, cod- 
liver oil, clams, oysters, lobsters, and crabs; eggs (10 to 20 per cent, 
of fat); animal and vegetable fats, bacon, suet, olive oil, cocoa butter; 
butter contains 85 per cent, fat, and should be used on meats, eggs, or 
spinach or melted in milk; rich cream; all cheeses (3 to 30 per cent, 
fat), especially Swiss varieties; vegetables, cress, tomatoes, cabbage, 
cauliflower, sprouts, artichokes, mushrooms, truffles, olives, onions, 
garlic, celery leaves, lettuce, cucumbers and radishes; of fruits, only 
whortleberries, young raspberries, and green gooseberries should be 
eaten, though fruit sugar (levulose) is better tolerated than starch 
or cane-sugar. Desserts, (souffles) of eggs, gelatin, and lemon; tea, 
coffee, diabetic cocoa (Rademann's) and von Hoevel's saccharin 
chocolate, may also be taken. 



916 CONSTITUTIONAL DISEASES 

To some cases, and in definite amounts, von Noorden allows the 
following (after determining the limit of tolerance, as outlined under 
Urine [glycosuria, v.s.] ) ; beans and peas (5j) ; turnips, carrots, celery 
bulbs, wax beans (5j); radishes (Bj); walnuts 6; hazel-nuts 10; al- 
monds 8; (no chestnuts); apples, pears, apricots, peaches (§j toij); 
berries (gss to j); cooked apples, plums, pears, peaches, cherries 
(5j); milk (8 to 9 g), (of which many practitioners allow a larger 
measure). 

Gradual withdrawal of carbohydrates is tolerated better than abrupt 
restriction. Glutin flours differ but little from ordinary flours in their 
percentage of starch. Aleuronat flour contains but half the starch 
of ordinary flour. Von Mehring believes that fat is best absorbed 
when some carbohydrates are given with it. If some starch can be 
given, Mosse prefers to allow potatoes which are more easily assimi- 
lated and contain but 16 to 24 per cent, of starch (bread contains 55 
per cent.). Ingestion of more than 5 ounces of butter daily may in- 
crease the /?-oxybutyric acid, but even 7 ounces may be taken if the 
butter is carefully washed in cold water, which extracts the lower 
fatty acids (von Noorden). Saccharin should be used in place of 
sugar, gr. iss daily; it is 280 times as sweet, and is antifermentative, 
but an excess may occasion dyspepsia. Naunyn advises an occasional 
fast day, and Austin Flint kept his cases in bed, and without food 
from Saturday night until Monday morning. As the disease is event- 
ually progressive, a schematic diet should not be insisted upon; 
reasonable restriction, with occasional dietetic treats is less often vio- 
lated by the diabetic, who is always hungry for bread and potatoes. 
The patient's weight, color and strength are of more significance than 
the urine. Though alcohol is a protoplasmic poison, it aids in the 
absorption of fat, prevents tissue waste, contributes energy and heat, 
and is a nervous sedative and cardiac tonic. 

Special diabetic treatment of the individual forms (according to von 
Noorden); (a) mild forms of glycosuria. In elderly persons it is not 
necessary to determine with great accuracy the sugar tolerance. The 
patient may eat bread, potatoes and vegetables according to his desire, 
for the quantity of sugar (1 to 2 per cent.) in the urine is usually 
insignificant. The older the patient and the more corpulent, the more 
careful should the physician be about reducing the body- weight ; fatty 
foods should be increased, butter being used freely on bread, potatoes, 
vegetables and meat; and the patient should have bacon, eggs, fatty 
cheese, light wine, coffee, tea and carbonated water (total of one to 
one and a half pints). Muscular exercise is essential, but should be 
regulated according to the bodily strength and condition of the heart. 
A course at Carlsbad is beneficial for obesity, gout or mild circulatory 
weakness. In young persons, carbohydrates should be given with 
much greater caution, as carelessness in diet is more frequent, and the 
glycosuria more often progressive. The limits of tolerance for carbo- 
hydrates should be closely watched. All carbohydrates must be for- 
bidden excepting bread and potatoes, in addition to which the patient 



DIABETES MELLITUS 917 

should have the following articles: 2 ounces of butter, with bread, 
cheese, and potatoes (480 calories) ; 2 eggs (150 calories) ; 3 to 4 ounces 
of olive oil with salad, cucumbers, etc. (90 calories); 1 ounce of fatty 
cheese (115 calories); 1 quart of milk (590 calories); and one ounce 
alcohol (210 calories) ; meats, v. s. (6) Moderately severe forms 
embrace cases in which the excretion of sugar is arrested or reduced 
to small amounts (1 to 2 per cent.) only by total abstinence from 
carbohydrates. The rise or fall of the tolerance limit should be 
watched every month, and every four or six months all carbohydrates 
must be withdrawn for three weeks. The diet must contain much 
fat; butter, 3 to 4 ounces (890 calories) must be weighed out every 
morning, and eaten on bread, vegetables, meat, fish, etc., either in 
solid form or melted. Olive oil, two-thirds of an ounce (186 calories) 
should be taken on salad (lettuce, chicory, cress, cucumbers, tomatoes, 
red cabbage), and the same amount as mayonnaise dressing for salad, 
cold meat, fish, lobster, etc. Bacon, two-thirds of an ounce (140 calories), 
5 eggs (390 calories), and one ounce of brandy (280 calories) should 
be given. In addition the patient should have meats, and some of 
the articles mentioned in the conditional list under general diet, (c) 
In severe forms, despite a continued rigid diet, sugar is constantly 
excreted. These cases usually occur in early life with emaciation, 
frequent complications and a fatal issue after a few months or years. 
Careful dietetic treatment may retard the progress of the disease, 
prevent complications, and delay the fatal issue. The dietetic treat- 
ment is the same as in moderately severe cases. Carbohydrates aggra- 
vate the diabetes, but cannot be wholly interdicted. Less starch and 
more fats and alcohol are given than in other cases. 

2. General Treatment.— Zimmer demonstrated the value of (a) 
exercise in lessening glycosuria, but as in obesity, we have to deal with 
an added factor, the improved appetite. The condition of the heart 
must govern the amount of exercise to be taken as Frerich early noted 
that fatal syncope and diabetic coma may occur after exhausting 
exertion, (b) The mouth and skin require special attention. Clean- 
liness averts in large part gingivitis, furunculosis and genital com- 
plications. Frequent warm (not cold) baths and change of underwear, 
gentle brushing of the teeth and soothing salves for eczema and 
similar eruptions are imperative, (c) Diabetics for the most part 
should be kept at home and at work, for they often become restless 
and desire to wander. A prolonged stay in a quiet place is better 
than travel. Sea bathing and exposure to cold and dampness are to 
be avoided, (d) Suggestive treatment may often be combined with 
the dietetic and medicinal therapy in depressed subjects, particularly 
in neurotics, (e) Mineral springs are suitable only for mild cases and 
those with obesity, gout and slight circulatory disturbance, in whom 
there is increased tolerance for carbohydrates. Carlsbad and other 
spas are contra-indicated in severe, youthful, very aged, reduced and 
nephritic cases. (/) The mode of life should be quiet, and avoidance 
of excesses is indicated. 



918 CONSTITUTIONAL DISEASES 

3. Treatment of Complications. — (a) Tuberculosis is the most serious 
complication. The liberal diet, necessitated by tuberculosis, is contra- 
indicated by glycosuria. A low altitude and mild climate should be 
selected, (b) Gastro-intestinal catarrh often precipitates diabetic coma. 
As in infantile disorders, starvation for one or two days is more effi- 
cient than attempts at intestinal disinfection ; only boiled water should 
be given; alcoholic stimulation is often indicated when there is ex- 
haustion, red wine acting as a stimulant and astringent, (c) Con- 
stipation (q.v.) should be relieved by rhubarb and sodium bicarbonate; 
severe purges must be avoided, (d) Nervous symptoms of the neur- 
asthenic order are observed in neurogenous diabetes ; sodium bromide, 
opium, codeine or acetanilide may be indicated. Of all remedies, opium 
alone exerts an appreciable influence upon the glycosuria; it was 
recommended by Dobson (1774); its affects are observed more in 
the severe than in the light type, i.e., it decreases the transformation 
of albumins into sugar, but does not control the transformation of 
carbohydrates into sugar; the average dose may be gradually increased 
without the patient exhibiting toxic symptoms, or suffering from its 
reduction afterward. Codeine may be given in doses of gr. j to x, 
though it is seemingly less effective than opium; it may be combined 
with sodium bromide 3 SS - Inunctions of mercury are seldom valuable, 
but are indicated when cerebral or pancreatic syphilis is suspected. 
(/) Neuralgia and neuritis should be treated dietetically; the salicy- 
lates, salol and aspirin may benefit mild cases as well as somewhat 
modify coincident gout or intestinal fermentation. (g) Acidosis, 
acetonemia, and diabetic coma are serious complications. Acidosis 
is said to be promoted by a rigid dietary (Naunyn, von Mehring); 
in pronounced acidosis even von Noorden, who opposed Naunyn's 
view, recommends an oatmeal diet, with butter aa Sviij at frequent 
intervals; he adds eggs to this dietary which is preceded for a few 
days by a vegetable diet. Some writers would also exclude fats. 
Sodium bicarbonate and sodium citrate 5ij to giij, t.i.d., and calcium 
carbonate 5j once or twice a day may possibly postpone threatening 
coma. Much water should be given by mouth, by rectum or sub- 
cutaneously with sodium carbonate giss to Oij. Developed coma is 
practicably incurable. Oxygen inhalations, alcoholic stimulation, 
strychnine, mild laxatives (not drastics) and subcutaneous or intra- 
venous injections are given, but rarely with success, (h) Gangrene 
should be treated expectantly until there is a possible halt in the 
process, and definite demarcation; positive rules of treatment are 
laid down with difficulty. In personal experience, advanced diabetics 
stand operative shock and anaesthesia poorly. Most of them have 
died from alarmingly rapid syncope or from typical dyspnceic coma. 
Other operations may be performed, when indicated as absolutely 
necessary life-saving procedures, and only, if possible, after strict 
dieting. Boils, furuncles, etc., are treated expectantlv. 



DIABETES INSIPIDUS 919 



(B). DIABETES INSIPIDUS. 

Definition. — A chronic malady characterized by large amounts of 
urine of low specific gravity. It was described by Willis (1674), who 
first differentiated between diabetes mellitus and insipidus (without 
taste, i.e., non -saccharine). It is uncommon; Eichhorst observed 
7 cases in 35,942 cases (0.02 per cent.), Futcher 7 in 403,535 (0.001 
per cent.), and 55 occurred in 113,600 in the Berlin Charite (0.048 
per cent.). 

Etiology. — Two groups of cases are observed: (a) the idiopathic 
(nervous or vasomotor) and (6) the symptomatic, which occur in (i) 
brain disease, especially basal syphilis and less often tumors of the 
medulla and the floor of the fourth ventricle, cerebral traumatism, 
basilar meningitis, apoplexy, hydrocephalus, and lesions of the middle 
cerebellar lobe or corp. trapezoides of the pons. (It is possible that 
the kidneys may be at fault, losing their power to concentrate the 
urine.) (ii) It may result from abdominal diseases, aneurysms, tumors 
or tuberculous peritonitis, (iii) Insolation, diabetic ancestry (Trous- 
seau), malnutrition (Ralfe) with tuberculous, syphilitic or gouty 
antecedents, acute infections and alcoholism are numbered among 
its possible causes. Most cases occur in males. In Strauss' collection 
of 85 cases, 10 per cent, were under five years old, 14 per cent, under 
ten, and 45 per cent, were between ten and twenty-five years of age; 
according to Jacobi, 25 per cent, occurs under ten years. Weil col- 
lected 23 cases among 91 individuals of four generations, all of whom 
enjoyed good health. Congenital cases are recorded, but are rare. 

Symptoms. — The onset is usually gradual, though abrupt symptoms 
have followed fright, (a) The urine is greatly increased; a secretion 
of 20 to 40 pints daily is not rare, and even one of 90 pints is on record. 
More urine is passed at night than by day. It is said that less urine 
is excreted than water ingested. It is passed rapidly after ingestion 
of water (tachyuria). Its specific gravity ranges between 1,000.5 
or 1,001 and 1,005. It is pale and the total solids are usually normal, 
though sometimes the urea, chlorides and phosphates are increased, 
being washed out from the tissues. Albumin, sugar and inosite are 
very uncommon. (6) Polydipsia is secondary, though it is perhaps 
the earliest symptom noticed. In one case, a physician with brain 
syphilis, 2 gallons of water were drunk each night between 10 p.m. 
and 7 a.m. (c) The skin is dry; carbuncles are rare. The saliva is 
decreased. The appetite is usually not increased, though phenomenal 
polyphagia marks some cases. Nervousness, headache, irritability, 
increased knee jerks, impotence and severe lumbar pain radiating 
into the legs, are quite frequent. Nutrition is often good in the idio- 
pathic cases, and no unusual metabolic findings are noted; in the 
symptomatic variety the condition of nutrition depends on the causal 
disease; in children growth may be retarded. The temperature is 
low and chilling occurs readily. Aside from obvious causal lesions, 



920 CONSTITUTIONAL DISEASES 

there is no constant autopsy finding except hypertrophy of the kidneys 
from increased activity, and sometimes dilatation of the bladder and 
renal pelvis. 

Diagnosis. — Diagnosis is easy, Differentiation is required (a) from 
diabetes mellitus, with which it has no common symptoms except 
polyuria and polydipsia; there is no glycosuria, acidosis, complicat- 
ing gangrene, carbuncles, or neuritis; (b) from interstitial nephritis, in 
which the specific gravity is higher, the urine is less abundant, is 
albuminous and contains casts, and which is associated with cardio- 
vascular, retinal and ursemic manifestations; (c) from primary poly- 
dipsia with secondary polyuria, which is exceedingly rare; and (d) 
from transitory polyuria, which is distinguished by its course alone 
as well as by its obvious etiology, as recent fever, hysteria, resorption 
of massive exudates, excessive medicinal diuresis, and transient ure- 
thral obstruction with sudden release of urine. 

Prognosis. — The prognosis is obviously more favorable in idiopathic 
forms, although cerebral syphilis doubtless causes many obscure cases. 
Less than one-half of the patients recover, though death results less 
frequently from the disease itself (save cerebral or abdominal tumors) 
than from intercurrent infections, notably pulmonary tuberculosis. 

Treatment. — Aside from antisyphilitic therapy, drugs are of little 
use. Iodides benefit some cases in which there is no reason to suspect 
syphilis, other than the therapeutic results. Opium may be useful, 
as in the saccharine form, and large doses are often well tolerated. 
Valerian (5j of the root, t.i.d.), gallic acid (gr. v to xx, t.i.d.), ergot 
(fluid extract ttj?xx, t.i.d.), sodium bromide (3ss t.i.d.), acetanilide 
(gr. v to x, t.i.d.), and electrotherapy are recommended. Strychnia 
has clearly helped some cases. Talquist considers a vegetable more 
efficacious than a meat diet. Posner advocates chewing gum which 
apparently decreases the polyuria and polydipsia. 



(0). GOUT. 

Definition. — An obscure metabolic disease, characterized by acute 
periodic or chronic inflammation of the joints with uratic deposits. 

Mentioned by Hippocrates, gout was clearly described by Thos. 
Sydenham (1683), who suffered from the affection for forty years. 
Murray Forbes (1792), and Wallaston (1797), recognized the uratic 
nature of the joint deposits. 

Etiology. — 1. The actual cause is unknown. In 1848, Garrod 
advanced the hypothesis that uric acid accumulated periodically 
(before the gouty seizure) in the blood. His, Vogel, and Magnus Levy 
and others deny Garrod's statement, and maintain that uric acid in 
gouty subjects is increased all the time; that the urine contains less 
uric acid before and more during and after the seizure. Pfeiffer 
holds that the uric acid is usually decreased, and that it is really less 
a question of its amount than of its insolubility or form. Again the 



GOUT 921 

idea is advanced that uric acid is not produced in excess, but is re- 
tained in the body because of periodic attacks of renal insufficiency. 
Whether the real metabolic change concerns the uric acid, the alloxuric 
or purin bodies is yet undetermined. 

2. The extrinsic, predisposing factors are somewhat better defined. 
(a) Heredity is an apparent factor in 50 to 60 per cent. ; transmission 
by the father is more common than by the mother, and the younger 
rather than the older children suffer from hereditary influences, (b) 
Mode of life; lack of exercise, over-eating, an almost exclusively meat 
diet, and alcoholism are potent factors. The old verse said that "Wine 
was the father, Eating the mother, and Venus the midwife" of gout. 
Though often true that gout affects the well-to-do (arthritis divitum), 
and arthritis deformans the poor (arthritis pauperum), gout is not 
uncommon among the lower classes. As alcoholism is a widespread 
scourge, it would seem that the heavy ales and beers of England and 
Germany are more injurious (in this respect) than whisky and light 
wine. Gout may occur in temperate individuals. Obesity, diabetes, 
arteriosclerosis, and calculous tendencies are concomitant or coordinate 
rather than causal conditions, (c) Lead poisoning is observed in 20 
per cent, of cases or more, particularly in England, and its relation 
to gout is puzzling, though saturnine nephritis may explain it. (d) Men 
are particularly prone to gout (1 to 13 or 25). (e) Age. Gout begins 
between thirty and forty years in 38 per cent., and thirty and fifty in 
60 per cent. Much less than 1 per cent, of cases begin before the 
seventeenth year, though Gairdner observed one case in a nursling. 
(/) England leads in frequency of its occurrence. In the United States 
it is rare, though Futcher shows that the cases in Baltimore and London 
hospitals stood as 2 to 3 (certainly not true for other American cities) ; 
again, relatively few cases seek hospital treatment. 

Symptoms. — These may be considered under two captions, (1) acute, 
and (2) irregular, chronic and visceral gout. 

1. Acute (regular, sthenic or) typical gout usually appears without 
prodromes, though an attack is sometimes heralded by digestive 
disorder (pyrosis, gastralgia, constipation), " cerebral congestion" 
(insomnia, vertigo, tinnitus, irritability, depression), paresthesia, 
cramps or pain in the muscles, dark lateritious urine or other vague 
symptoms. The paroxysm is remarkably characteristic, (a) Local 
findings: The patient is awakened one to three hours after midnight, 
by an agonizing pain in the metatarsophalangeal joint of the large 
toe {podagra). The pain is described as crushing by a vise or like 
burning by a hot iron. Localization in the toe is so frequent (95 per 
cent., Garrod, or 73 per cent., Scudmore) as to be practically diag- 
nostic of gout. The skin over it becomes hot, red, tense, slightly 
cedematous and exquisitely sensitive. Serum exudes into the joint. 
The pain abates toward morning, but the inflammation increases. 
Each early morning sees a repetition of the pain for three to five or 
less often for six to seven days; the paroxysmal pain and the local 
findings then gradually subside by lysis; in two-thirds of the cases, 



922 CONSTITUTIONAL DISEASES 

the skin desquamates over the joint. Later attacks may involve the 
thumb, knee and other joints, though less commonly than in chronic 
irregular gout (v.i.). The local symptoms vary in intensity; as a rule 
the shorter the attack, the severer are the symptoms. The pathological 
changes probably develop in this sequence: (i) local stasis (inflam- 
mation), (ii) necrosis, and (iii) uratic deposit; the ordinary urates 
(biurate of sodium in conjunction with sodium phosphate) do not 
cause such local reaction, but the biurate alone, even in most dilute 
solutions (0.004), produces inflammation (Pfeiffer); acute residual 
swellings (acute gouty tophi) consist of this biurate which has been 
precipitated by the carbonates of the blood (and tissues). Conval- 
escence is complete in ten to fourteen days, often with greatly improved 
spirits and health after the gouty attack. During the seizure (b) con- 
stitutional symptoms are not absent. The temperature rises to 100.5° 
or 101°, rarely over 102°. The pulse is usually slow and hard, some- 
times arrhythmic and seldom exceeds 100. The heart may palpitate. 
Furring of the tongue, slight leukocytosis, anorexia, nausea, vomiting, 
epigastric cramping and eructations are not uncommon. The urine 
is dark, usually decreased, acid, and higher than normal in specific 
gravity; the difference of opinion regarding uric acid has been men- 
tioned under etiology; Bain and Futcher find a close parallelism 
between the uric and phosphoric acids, both being derived from dis- 
integration of nuclein; they both fall below normal in the quiescent 
period and increase during the attack; sometimes the indican and 
urobilin are increased. Garrod's test for urates in the blood, exudates 
or transudates, consists of allowing it to clot, adding 10 drops of 30 
per cent, acetic acid to 5*j of the serum, and obtaining the crystals 
after twenty-four hours. 

Subsequent acute seizures may sometimes be averted by diet and 
exercise, but they are likely to recur, notably in the spring and fall. 
Excesses in alcohol or in eating may precipitate acute gout; indeed 
in one case it would occur within fifteen minutes from drinking a 
glass of champagne; trauma, exertion or excitement may favor relapse. 

Retrocedent or suppressed gout was once thought to develop when 
an acute paroxysm abated "too rapidly"; many symptoms attributed 
to it are doubtless due to coincident arteriosclerosis or uraemia (e.g., 
gastralgia, vomiting, cardiac pain, dyspnoea, delirium, convulsions, 
apoplexy, coma and death). 

2. Chronic, irregular, atypical gout generally follows acute attacks 
which increase in frequency, decrease in acuity and show slight ten- 
dency toward resolution. Pfeiffer claims that gout deposits (tophi) 
cannot occur without acute attacks. In some cases it appears to 
begin as chronic gout, particularly in the aged, the cachectic and in 
women with a gouty family history, all of whom lack reactive power 
(atonic or asthenic gout), (a) Local findings: there is less pain, fever, 
and redness but greater and more permanent swelling than in the 
acute form, until the condition eventually becomes fixed and chronic; 
the "attacks" may be most rudimentary, and remissions may alternate 



GOUT 923 

with exacerbations. The lower extremities and hands are most often 
affected; it may also develop in the thumb {chiagra), knee (gonagra), 
elbow (pechiagra), and spine (rhachisagra), but the shoulder is very 
seldom and the hip almost never invaded. In some cases its moving 
from joint to joint (urarthritis multiplex seu vaga) may cause confusion 
with acute rheumatism. Uratic deposits (tophi arthritici) form in 
the cartilage and later in the capsule and ligaments, and the swelling 
never recedes essentially. These prominences, and the attendant 
fibrosis, lead to deformation, subluxation, crackling on movement, 
ankylosis and contractures. Sometimes fluctuation is noted, especially 
in the big toe. The proximal joints of the fingers may point to the 
radial, and the others to the ulnar side. Tophi may rupture, evacuat- 
ing yellow- white urates, though incompletely, as they are partly diffused 
through the tissues; these gouty ulcers heal tardily, if at all, for their 
basis is fibrous and but slightly granulating tissue. Tophi occur 
also on the ear (25 per cent.), bursa?, tendons, aponeuroses (which 
may explain some of the cases of Dupuytren's palmar contracture), 
and even in the skin, eyelids, nose, larynx, penis or scrotum. (6) 
Visceral gout includes a curious mixture of real gouty complications 
and incongruous doubtful symptoms ("gouty disposition," arthritisme, 
herpetisme, and the so-called "uric acid diathesis"). 

Complications. — Renal complications are the most important visceral 
complications, and sometimes dominate the clinical features. In 1,440 
cases, Garrod observed albuminuria in 26.5 per cent., more often in 
advanced than in early cases. Its exact relation to gout is hard to define ; 
it may follow the metabolic changes, or according to Ebstein may pos- 
sibly constitute a primary gout. At first albuminuria may be con- 
sidered toxic, marantic, congestive or arteriosclerotic but later the 
renal, cardiovascular and retinal findings of interstitial nephritis 
develop with all its accidents and complications; uratic deposits 
occur in the intertubular tissue and sometimes in the secreting tissue 
of the cortex and medulla, in 15 per cent, of cases, according to Moore. 
Uratic deposits (calculi) are not uncommon in the renal pelvis; hsema- 
turia, oxaluria, pyelitis, cystitis (and perhaps urethritis) may also 
occur. 

Arteriosclerosis of the ordinary type is promoted by the individual's 
mode of life, by metabolic changes, alcoholism, plumbism and nephritis; 
it develops early and causes many (and, with nephritis, most) of the 
so-called visceral gout symptoms, as the cerebrospinal (headache, 
vertigo, brain congestion, epileptiform and apoplectiform attacks, 
encephalomalacia, myelitis"), the circulatory (cardiac hypertrophy, 
myocarditis, aneurysm, angina pectoris, atheromatous valvular lesions, 
phlebosclerosis), and the respiratory symptoms (stasis, bronchitis, 
asthma), and retinitis. 

Eczema (18 per cent.), scleritis and episcleritis (with small circum- 
scribed points of inflammation, and sometimes semimicroscopic tophi), 
neuralgia or less often neuritis, lumbago, sciatica and pain in the 
brachial plexus, burning and psoriasis-like patches on the tongue, 



924 CONSTITUTIONAL DISEASES 

digestive symptoms (v. Prodromes), and burning in the eyeballs are 
probably often gouty. On the other hand, the " gouty disposition" — 
in some descriptions — consists of very vague symptoms; on analysis 
neurotic, paroxysmal (calculous colic, migraine or asthma), and other 
conditions which are common in persons not suffering from gout, 
account for many so-called visceral gouty manifestations. 

Diagnosis. — (a) Acute gout is most typical in its etiology, history 
and localization, with acute, circumscribed redness. In a few cases 
(urarthritis multiplex), a diagnosis of acute articular rheumatism may 
be made; fibrous rheumatic nodes may be confused with tophi, but 
if the possibility of gout is recognized, there is usually no error, (b) 
Chronic gout often has a history of acute attacks, usually involves the 
extremities and distal joints of the hands and feet, is marked by unequal 
distention and thickening of the soft parts, and is often known by its 
association with early arteriosclerosis, contracted kidney, obesity, renal 
calculus and diabetes. The arrays cannot determine the diagnosis 
(see Arthritis Deformans, Diagnosis). Visceral gout is an entity 
only when it develops in a patient who is undoubtedly gouty. 

Prognosis. — Gouty patients may live to an old age, but the usual 
recurrence every two months to two years gives a tendency to chronic 
gout, of which the issues are (a) ursemia, (b) arteriosclerotic compli- 
cations, as coronary disease or apoplexy, (c) terminal infections as 
pericarditis, pneumonia, and pleurisy, which may be induced by the 
id) gouty marasmus or cachexia. In general the outlook is better 
in frank gout than in irregular gout, and better in cases which develop 
after forty years of age. 

Treatment. — 1. The Acute Paroxysm. — (a) Absolute rest is indi- 
cated. (6) For pain, the use of colchicum is empirical; some prac- 
titioners believe that it increases the elimination of uric acid, though 
the claim that it enables the tissues to break down, and dispose of 
the uric acid seems more reasonable; nevertheless, it causes the dis- 
appearance of uric acid from the urine of those passing it in quantities, 
and in gout it relieves pain and inflammation and acts as a cholagogue; 
5iss of the vinum colchici radicis (not seminis) should be given daily. 
It must be administered with care in nephritic and marantic subjects. 
If long used, a tolerance to its action is acquired. It should be stopped 
when pain is alleviated and it does not act well when diarrhoea inter- 
venes, which interferes with its diuretic effect. (Full therapeutic doses 
produce a slow pulse, nausea, vomiting, pain and purging; inversely 
to its action on the bowels there is diaphoresis and diuresis. It is 
eliminated by the kidneys, bowels and skin. After toxic doses, great 
nausea, retching, serous and finally hemorrhagic purging, great pain, 
headache, vertigo, prostration, paralysis of the peripheral sensory nerves, 
motor part of the cord and finally of the respiratory centre [the usual 
cause of death] develop ; ecchymoses of the gastro-intestinal tract with 
swelling may be seen at the postmortem examination.) 

If colchicum produces no effect, sodium salicylate should be given, 
gr. xv every two hours (5j to ij daily); it usually relieves the pain 



GOUT 925 

and swelling, and probably aids in solution of the uric acid ; its early 
effect is greatest, and it usually fails after the second or third day. 
Finally, phenacetin (gr. viij to x) and morphine are indicated in severe 
paroxysms. In prolonged attacks, potassium iodide gr. v (which 
should be given with care in nephritis), and wine of colchicum tt#x are 
useful, (c) The diet, according to Pfeiffer, should consist of foods 
which "release uric acid in a free form," as meal soups, rice and 
other carbohydrates; meat and eggs should be withheld (though 
given in chronic forms, and in the intervals between attacks). Plain 
or acid water, as Seltzer (not alkaline water as Vichy) should be given 
freely; alcohol and lemonade must be forbidden. If laxatives are 
indicated, calomel, rhubarb or castor oil should be used, (d) Local 
measures should be largely avoided lest added necrosis and tophi 
develop; especially, vesicants, the use of the ice-bag and massage; 
warm applications of 50 per cent, alcohol or lead water (tinctura opii, 
liquor plumbi subacetatis, aaSij and water gj) may be used. 

2. The Interval Between Attacks. — (a) Regulation of diet is the 
cardinal indication. Moderation in the quantity is more important 
than the quality of the food. Quantity: a full diet increases the uric 
acid, taxes resorption which is usually impaired, and favors acid 
fermentations which engage the diphosphates and carbonates of the 
food necessary for the formation of soluble uric acid salts; three 
medium-sized meals a day are allowed. Quality: (i) alcohol should be 
absolutely forbidden; (ii) water may be given freely, little with the 
meals but large amounts on an empty stomach, (hi) Moderate 
amounts of fat are allowed, (iv) Fruits and vegetables increase diuresis, 
and their malates and citrates help to dissolve the uric salts, (v) 
Meats are allowed (though there are various opinions on this subject). 
The urea they produce seems to dissolve uric acid which the meat, 
if given in moderation, does not increase. Meat is essential partic- 
ularly in marantic cases. There is no difference between the effect 
of light and dark meats; those rich in nuclein (sweet-breads, liver, 
and kidneys) must be avoided, (vi) Carbohydrates should be largely 
decreased; this rule is empirical, though it appears that following 
their ingestion the uric acid (as compared with the urea) increases 
nearly two-fold. Milk should be avoided, for its lactic acid is injurious. 
(b) Exercise is indispensable, but prolonged or fatiguing effort, hurry 
and worry are to be avoided, (c) Medicinal treatment is rather second- 
ary. Alkalies produce an increased output of uric acid, but they 
operate only by preventing decomposition of the neutral (bi-) sodium 
phosphate (the chief uric solvent). The kind of alkali used is not 
essential; lithium carbonate is inferior to sodium carbonate or bicar- 
bonate, which act first by promoting the formation of bisodium phos- 
phate, and second by neutralizing the acid formed by fermentation ; 
it may be given (in doses of gr. x upward) for a long period of time, 
and has no effect on the blood; but the twenty-four-hour collection of 
urine should not become alkaline (lest alkaline deposits in the renal 
pelvis develop). Mineral waters merely operate in the same way, as 



926 CONSTITUTIONAL DISEASES 

those of Saratoga, White Sulphur, and Bedford Springs in this country, 
Bath and Buxton in England, Aix-les-Baines, and Contrexeville in 
France, and Fachingen, Carlsbad, Homburg, Wildbad, and Teplitz. 
Luff advises the use of guaiacum resin, gr. v to x, t. i.d. Piperazin, 
lysidin, urotropin, urosin and sidonal are much inferior to the simple 
sodium salt. 

3. Chronic Gout. — This is difficult to treat. For general dietetic, 
hygienic and medicinal measures, see above. Colchicum wine, ttjjx, 
and potassium iodide, gr. v to x, may relieve the condition of the 
joints and the gouty asthma, neuralgia, and eczema. Tonics, prin- 
cipally arsenic, are indicated in marantic forms. Tophi should not be 
operated on; local measures are useless, save gentle massage, dry 
heat, moist applications or salicylate salves at night (ac. salicylic. 4, 
lanolin 40, and oleum terebinthinae 1 part), though all treatment 
generally fails. 



(D). ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM. 

After excluding gouty, tuberculous, syphilitic, gonorrhceal and hemo- 
philic affections, there remains a group of articular affections of which 
the chief are arthritis deformans and the so-called chronic rheumatism. 
It is almost certain that a number of totally different affections are 
gathered under these names. Their classification is most unsatis- 
factory. 

Arthritis deformans, which has been noted in Egyptian mummies, 
is a progressive or at least chronic affection, marked by changes in 
the synovial sac, cartilages and bone, causing functional disturbance 
of, and usually deformity in, the articulations, usually symmetrical 
and polyarticular; also called rheumatoid arthritis, and chronic 
deforming rheumatism. 

Etiology. — (a) The predisposing factors are (i) heredity, which is 
causative in from 2 (Charcot) to 13 per cent. (Garrod); (ii) age; 55 
per cent, of cases occur between twenty and fifty years of age; 5 per 
cent, under twenty years and 40 per cent, over fifty years of age (Gar- 
rod); (iii) sex; though Stewart and McCrae consider that the sexes 
are equally involved, Garrod observed 82 per cent, in women (for 
the disease possibly sustains some relation to the genital functions); 
(iv) fatigue, cold, dampness, poor hygiene, trauma or sorrow may 
also be predisposing factors. 

(b) The immediate cause is unknown. There are many theories: 
(a) the neuropathic theory (Mitchell), is that it results from a cord 
lesion; this is now nearly abandoned; (b) the infective theory is based 
upon finding bacteria in the joints, enlarged spleen and lymph glands, 
and its occasional development after influenza, angina, and scarlatina; 
Scheuller found a bacillus, Chauffart a diplococcus, and Bannatyne 
and Blaxall have described microorganisms of inconstant types; (c) 
the rheumatic theory, according to which it is a chronic rheumatism; 



ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM 927 

Garrod and Bannatyne find few heart lesions, though Pribram finds 
about one-fifth as many as in rheumatism. 

Pathology. — Whether the synovia or cartilages are first involved is 
undetermined; the arrays do not solve the question; practitioners, 
who see cases early, hold that the serous sac is first affected, and sur- 
geons find the cartilage most often diseased. The synovial villi hyper- 
trophy and the cartilage slightly fibrillates, cleaves, and finally atrophies. 
The bone becomes thin in some places and tuberous in others (Hay- 
garth's nodosities) from periosteal proliferation; the joint surfaces 
become eroded and in part grow together. 

1. Diffuse Progressive Type. — (a) The acute form is uncommon. 
There is some fever, rise in the pulse rate, and depression, and the 
joints become red and swollen, resembling in some ways acute artic- 
ular rheumatism, but differing from it in several essential points; 
that is, arthritis deformans is less fugitive, involves perhaps the small 
joints more frequently, is attended by less sweating and very seldom 
by heart complications, does not react to salicylates and runs a much 
longer course. In some cases it has even resembled typhoid, because 
the fever and splenic enlargement lasted for some time before the 
joints became affected. (6) The more frequent chronic form develops 
insidiously, with uncomfortable sensations in the joints, pain or tear- 
ing nocturnal pains about the joints, and vasomotor skin symptoms. 
It begins most often in the small joints of the hands, with or without 
swelling, and remits and recurs. The hands often sweat. The fingers 

Fig. 48. 




Rheumatoid arthritis. (Musser.) 

become fusiform from changes in the joints, capsular thickening and 
collateral oedema which separate the fingers from each other. The 
cedema often disappears, showing more clearly the bone and the cap- 
sule thickening. The cartilages become uneven and crackle on move- 
ment, loosened villi may become free bodies, and the adjacent bursas 
and tendons may become swollen. The fingers deviate and become 
angular from flattening of the saddle-shaped epiphyses and muscular 



928 CONSTITUTIONAL DISEASES 

contractures (now extensor and again flexor in type). Extension to 
other joints occurs; the elbow becomes flexed, the shoulder often 
crackles and becomes fixed; the large toe is bent out, and lies under 
the other toes which are often extended at their first, and flexed at 
their two distal articulations; the ankle is often abducted; the knee 
is swollen, shapeless and flexed from fluid effusion or contracture; 
in a few cases the hip, jaw, and spine are involved. 

Motion is limited by the swelling, muscular contractures, fixation 
of the joints by interlocking extracapsular nodosities, and capsular 
induration. The contiguous muscles atrophy from disuse, local 
inflammatory invasion or reflex influence on the cord. The skin 
may become puffy, glossy or even atrophic. The reflexes are chiefly 
increased, as the patellar (in 80 per cent.). Neuritis is not uncommon. 
In 64 cases in which the vertebra? were involved, Braun found nervous 
symptoms in 88 per cent., as weak muscles, occipital neuralgia, involve- 
ment of the brachial plexus and anaesthesia. The heart was not affected 
in any of Garrod's 500 cases. Anaemia, episcleritis and other compli- 
cations are uncommon. The majority of patients do not improve or 
recover, and recurrence of the disease is very common. In some 
cases the process is arrested. Aside from atheroma and nephritis 
few intercurrent diseases develop. 

2. Partial or Monarticular Type. — Pathologically this type resem- 
bles the form described, but differs from it in that it presents more 
profound changes, and is limited to one or few articulations. There 
is the same capsular thickening and cartilaginous fibrillation; the 
cartilage often softens, ossifies or hypertrophies; the bone rarefies 
or becomes cystic and soft in some places, with flattening of the bone 
heads and widening of the sockets, particularly in the shoulder and 
hip; in other places bony over-growths form, known as Haygarth's 
nodes, or a new socket may develop; the bone may eburnate and the 
joint may be either smooth or ridged. As a rule the atrophic prevail 
over the hypertrophic changes. They resemble the extreme senile 
change (morbus coxoe senilis); trauma or a nervous basis are 
considered causal; it occurs in old persons and largely in males. 
Clinically, compared with the general progressive type, it is single 
or at least rarely symmetrical, occurs in the proximal large joints 
(hip and shoulder), and is less often attended by subluxation. The 
elbow, spine and smaller joints are less involved. 

3. Vertebral Type. — Struempell (1885) named this type chronic 
ankylosing spondylitis; vertebral arthritis deformans occurs with 
ankylosis of the spine, shoulders and hips. Marie (1898) made it a 
separate type (spondylose rhizomyelique), characterized by complete 
vertebral ankylosis, scoliosis, ankylosis of shoulders and hips, exemp- 
tion of all other joints, incidence almost exclusively in males, and its 
appearance in the young immediately after bony development has 
ceased. Von Bechterew (1892) described a similar type due to hered- 
ity, trauma or meningeal inflammation and characterized by paresis 
of the muscles of the neck, trunk and extremities, some atrophy of 



ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM 929 

the back and shoulder, signs indicating involvement of the spinal 
nerves (hyperesthesia, pain and paresthesia), and an ascending 
degeneration in the cord. These are probably but subtypes of arthritis 
deformans. 

4. Juvenile Type of Still. — (a) The ordinary progressive (adult) 
form may be observed, running an unfavorable course, and often 
with almost universal ankylosis; in some cases the great toes are 
lengthened, (b) "Still's type" occurs in poor children largely; 70 
per cent, of cases are girls; 30 per cent, occurs between the second 
and seventh years, 32 per cent, between the seventh and thirteenth 
years, and 20 per cent, between the thirteenth and seventeenth years. 
The onset is often subacute. The multiple arthritis affects chiefly the 
extracapsular tissues, and there is seldom crepitus. The spleen is 
always enlarged, and the lymph glands near the affected joints are 
hard and large. Anemia and retarded development are common. 

5. Heberden's Nodes. — Bony nodes develop on the sides of the end 
phalanges near the joints. They begin between thirty and forty 
years, but are seen chiefly at about sixty years of age. Though at 

Fig. 49. 




Heberden's nodes. (Musser.) 

first soft, and sometimes painful and red, they become hard, indolent 
and as large or larger than a pea. Their growth is more often inter- 
mittent than continuous. Some disturbance in function is not uncom- 
mon, but only in extreme cases is deformity observed, as flexion of the 
end phalanges into the palm or deviation toward the radial side. 
Involvement of the large joints is rather uncommon, whence the 
prognosis is favorable. Some consider them gouty, though Heberden 
dissented strongly. 

Diagnosis. — (a) In gout, the history, localization, fine (not coarse) 
crackling in the knee-joint and radial articulation of the elbow, greater 
spontaneous pain, infrequent generalization and symmetry, the uratic 
deposits and tophi in the ear are characteristic, (b) Acute rheumatism 
(v.s. Acute Form), (c) Multiple tuberculous arthritis may cause diag- 
nostic difficulty, particularly when it occurs in children, for pulmonary 

59 



930 CONSTITUTIONAL DISEASES 

tuberculosis may complicate arthritis deformans; but the tuberculous 
hip and knee involvement, the fusiform fingers, the hectic fever, involve- 
ment of the glands and serous membranes are generally distinctive. 
Poncet has recently called attention to an ankylosing tuberculous 
pseudorheumatism, which may cause confusion (v. Tuberculosis). 
(d) Syphilis (q.v.) of the joints occurs particularly in persons between 
four and fifteen years of age, and in about 40 per cent, of hereditary 
forms; the epiphyses are irregularly deformed, (e) Hemophilic 
arthritis is distinguished by the unmistakable family history and its 
three stages (i) hsemarthros, (ii) panarthritis, and (iii) adhesions, 
erosions, deformity and ankylosis. (/) Chronic articular infections 
(chronic pseudorheumatism), especially subchronic and chronic gonor- 
rhceal arthritis (q.v.), begin acutely, usually affect the knees first, 
then possibly after months the ankles, hands (in women particularly), 
and sternoclavicular and other joints; similar chronic arthritides may 
follow scarlatina, diphtheria, pneumonia, and grippe, (g) Nervous 
arthropathies present much the same pathological findings; (i) the 
arthropathies of tabes (q.v.), occur rapidly and early, without pain, 
tenderness or other inflammatory evidence; are attended by much 
effusion, are atrophic or flail-like rather than hypertrophic, in 80 per 
cent, involve the lower extremities and are accompanied by other 
signs of tabes, (ii) In syringomyelia (q.v.) the effusions are great, 
painless, in 80 per cent, involve the upper extremities, and are asso- 
ciated with the syringomyelic dissociated anaesthesia, and panaritia. 
(h) "Chronic rheumatism" follows acute rheumatism, in which the 
changes involve less the bone, cartilage and serous sacs .than the 
capsule which becomes fibrous. The cartilage may become somewhat 
fibrillated and fibrous but is seldom hypertrophied or destroyed. The 
vascular bands become callous (Jaccoud's fibrous rheumatism), and 
ankylosis may result. It is maintained by some that this ankylosis 
of connective tissue, and the joint obliteration differentiate fibrous 
rheumatism from arthritis deformans, but clinical differentiation is 
often impossible. 

Treatment. — Treatment is notoriously futile and arrest of the pro- 
cess results rather from spontaneous exhaustion of the disease than 
from therapeutic efforts, (a) "Rheumatic" influences, as exposure to 
cold and dampness, overheating while at work, and resting in damp 
garments are to be carefully avoided. Woolen underwear should be 
worn. General hydrotherapeutic measures are illy borne. A warm 
climate benefits especially those cases resembling (or including) chronic 
fibrous rheumatism, as that of Mexico, the Hot Springs of West 
Virginia and Arkansas, (b) Diet is not of such importance as in 
gout; indeed, liberal feeding is strongly indicated. (c) In acute 
exacerbations rest and coal-tar derivatives are indicated; salicylates are 
generally useless save in really secondary rheumatism, (d) Passive 
movements and massage relieve stiffness and muscular contractures. 
Massage reduces the oedema and adhesions. In some cases forcible 
pressure, as with the thumb, will cause some absorption of the (fresh) 



RICKETS 931 

osteoplastic nodes; it may be easily overdone, and once every day or 
two on the same area is sufficient. Cautious active exercise is also 
essential, (e) Extension by pulley weights sometimes produces wonder- 
ful results according to Hoffa, in lessening pain and exostosis, though 
the author has never observed any essential results. (/) Local measures 
may be of some use. The x-rays and strong electric lights may afford 
temporary alleviation from pain but do not seem to affect the basic 
change; cases of fibrous rheumatism are more benefited than arthritis 
deformans. The same may be said of local applications of warm 
water. Hot air causes hyperemia of the parts and is sometimes of 
real (temporary) benefit; cages of wire, asbestos and felt are devised 
to enclose the joint, leaving around it an air space; the temperature 
is gradually raised by a lamp placed under a connecting elbow to 
200 or 250° F. and is gradually lowered. Bier's method of venous 
hyperemia, used by him in treatment of tuberculous joints, is also 
advocated; the Esmarch constrictor above the joint should produce 
swelling but not pain. "Firing" the skin with the Paquelin is bene- 
ficial in lighter grades of deforming arthritis and in fibrous rheumatism. 
Encouraged by the results in one case in which injections of iodoform 
and olive oil were given, the author used it in six other cases, and 
either without benefit or with great increase of pain and swelling (the 
injections were made with absolute asepsis). Operation (resection) may 
be considered in nonprogressive, monarticular forms, but the general 
poor health and age of the patient rather contra-indicate it. (g) In- 
ternal medication as cod-liver oil, arsenic and syrup of the iodide of 
iron may seemingly help a few cases. Luff uses guaiacol carbonate 
with marked success; the initial dose of five grains, t.i.d., is increased 
two grains every week till a single dose of twenty grains is given. 



(E). RICKETS. 

Definition. — A metabolic affection of early infancy, characterized 
chiefly by hyperemia and deficient calcification of the growing bones. 
The disease was first well described by Glisson (1650). The name 
is derived from an old English word meaning " twisted," and Glisson 
suggested the Greek "rhachitis" (vertebral inflammation) because the 
spine was often involved, and the term sounded like " rickets. " 

Etiology.— Its etiology is obscure. All theories advanced, such as 
deficient absorption of lime salts or infection, and reduced activity of 
the thymus, are insufficient, (a) The diet seems to be of prime im- 
portance; proprietary foods, condensed milk, cow's milk, excess of 
carbohydrates, prolonged lactation or nursing during pregnancy are 
probable factors. Cheadle considered that a deficiency in animal fats 
and proteids was causative; after 20 litters of lion cubs had been lost 
from rickets in the London Zoological Gardens, Bland Sutton found 
that a diet of milk, powdered bone, meat, and cod-liver oil prevented 
rickets. (b) Unsanitary surroundings may be causal, as lack of fresh 



932 CONSTITUTIONAL DISEASES 

air and sunlight, crowded quarters and kindred factors observed 
largely among the poor classes in large cities, particularly in Europe. 
Among nurslings Kassowitz (Vienna), observed it in 89 per cent., 
and Joucousky (St. Petersburg) in 90 per cent.; in children's clinics 
abroad, Marfan (Paris) found rickets in 50 per cent.; in Holland, 
London, Christiana, Naples, and Rio Janeiro about the same figures 
(50 to 80 per cent.) prevail; in the United States it is most frequent 
among negroes and Italians. Hereditary syphilis is a predisposing 
factor, (c) Age may be of etiological importance. In more than 600 
cases, Baginsky did not observe it in children under three months of 
age; his figures show 7 per cent, in children between three and six 
months, 28 per cent, in those between six and twelve months, 35 per 
cent, in those between one and one and a half years, and 18 per cent, 
in those between one and a half and two years (e.g., 88 per cent, of 
cases occurred in children between three months and two years of 
age). The occurrence of congenital rickets (apart from achondro- 
plasia, see Diagnosis of Barlow's Disease) is usually denied but 
there is some authoritative testimony for it. Rickets which develops 
later, up to puberty, is called rhachitis tarda. 

Symptoms. — An experienced observer may diagnosticate the gradual 
onset from the prodromes, as the irregular or tardy dentition ; restless- 
ness, irritability, insomnia and throwing off of the bedclothes ; sweat- 
ing, particularly about the head and neck; bronchitis; digestive 
disturbances, coated tongue, anorexia, malnutrition, meteorism or 
diarrhoea; immobility, the child crying when moved or touched, and 
general hyperesthesia. However, a positive diagnosis is not justifiable 
until the bone symptoms develop. 

1. Bone Symptoms. — (a) The skull usually shows the earliest 
changes, generally in the first year of life, and the bone changes (v.i.) 
are most marked in the skull and thorax. The face appears small 
and the head large. Nodes or bosses of bone appear on the frontal 
and parietal regions, which with the occipital flattening produce the 
caput quadratum (tete caree) ; the head may be dolichocephalic. The 
anterior fontanelle increases forward, and in some cases all the sutures 
open toward the end of the first and beginning of the second year. 
The fontanelle and sutures (which normally close about the fifteenth 
or eighteenth month) remain open, even until the fourth year (i. e., 
there is lack of normal involution). The occiput softens (craniotabes) 
in 33 to 50 per cent., near the lambdoid suture; the occipital protuber- 
ance remains hard. Craniotabes may less frequently occur elsewhere, 
as in the frontal bones; besides the actual bone changes (v. %.), the 
pressure of the pillow and of the brain further its development. In 
extreme cases the peri- and endocranium actually touch, and in 
moderate degrees the skull feels "parchment-like." Though it is 
not absolutely pathognomonic of rickets, and though it occurs also in 
syphilis, craniotabes is rather characteristic when there are also the 
tender quadrate head, head sweating, thin occipital hair and blue 
scalp veins. Craniotabes may be an element in the general and local 



RICKETS 933 

spasms which occur in rickets. The frequent systolic murmur heard 
over the greater fontanelle is also heard in other affections or in 
health; it seldom endures beyond the fifth year, and is said to occur 
only in conjunction with a similar bruit in the carotids. The upper 
jaw becomes long and narrow, and the lower jaw becomes hexagonal, 
probably from muscular traction on the soft bones. The eruption of 
the teeth is delayed; they do not appear until the second or even the 
third year; the second teeth are crowded, carious, curved and eroded. 
(b) In the thorax, the rhachitic " rosary " appears toward the end of 
the first or early in the second year; it is so-called from the bead-like 
succession of enlarged chondrocostal joints; they are enlarged epiphy- 
ses. The chest itself is altered toward the middle or end of the second 
year; this is due to the softness of its bones, the traction exerted by 
the diaphragm, atmospheric pressure and sometimes by external 
influences, as holding of the child with a hand on the chest, or coinci- 
dent respiratory inflammation. Louis' angle is often prominent, 
and the sternum juts forward, causing "chicken breast" (pectus 
carinatum). There is also a depression outside of the costochondral 
junctions which extends outward and downward, and is accentuated 
by some eversion of the costal arch. The thoracic deformity promotes 
respiratory complications and dyspnoea, which in turn aggravate 
it. With the deformity of the chest, we may group lumbar kyphosis 
which is arcuate and not angular, the thickened or bent clavicle 
and the thickening of the spine or edges of the scapula, (c) In 
the extremities, the epiphyses, particularly of the ulna, radius, tibia 
and fibula, are enlarged; this occurs at the end of the first or 
beginning of the second year at the same time as the rosary, cranio- 
tabes and wide fontanelle. The epiphyses, like the ribs and skull, 
are tender and painful. It may look as though there were "double 
joints." Deformities may develop from muscular traction or from 
the weight of the body; the arms may incline outward and forward; 
the forearms may become convex toward their extensor surfaces. 
The thighs sometimes become convex anteriorly and outwardly; the 
legs bow outward or less often forward, especially when early walking 
is allowed or encouraged. Spiral or other extreme deformities are 
less frequent. The gait is waddling. Greenstick or actual fractures 
sometimes occur, (d) The flat rhachitic pelvis develops by the weight 
of the body pushing the sacrum into the pelvis and the counter-pressure 
of the thighs narrowing the anterior pelvis, so that the pelvic aperture 
may become heart-shaped; the acetabula lie more anteriorly, and the 
iliac crests flare outward, (e) Pathology of the bone affection. Nor- 
mal bone grows in length as follows: there are two zones in the epi- 
physeal surface facing the shaft; (a) the first zone is nearest the shaft, 
is faintly yellow, and measures j mm.; it is the zone of preliminary 
calcification, into which normally the bloodvessels grow, and form 
medullary canals by absorbing small areas of bone, and in which 
osteoblasts appear and calcification develops. (In rickets the calci- 
fication is imperfect and irregular in this zone, and the bloodvessels 



934 CONSTITUTIONAL DISEASES 

grow not merely into these calcified areas but beyond them, even 
into the cartilage area, and absorb what little new bone is formed. I 
h The -second zone lies outside the one described, is sharply demarked 
from it. is normally bluish, measures 1 to 2 mm. in thickness, and is 
known as the hyperplastic zone, in which the cartilage cells divide 
and proliferate. In rickets this zone becomes larger, proliferates 
irregularly and is invaded by bloodvessels, and irregular foci of abor- 
tive calcification: the demarkation between the first and second 
zones is ill-defined . Normal bones grow in thickness by bony increase 
beneath the periosteum. In rickets this layer becomes several milli- 
meters thicker, irregular and nodose . t Normal bone develops in the 
skull and face in the connective tissue. In rickets the lime salts are 
either not deposited, are insufficiently deposited [craniotabes] or over- 
deposited as bosses [osteosclerosis].; The essential element of these 
rhachitic changes is undue hyperaimia and irregular, deficient calcifica- 
tion: which one is primary remains a disputed point; the bones may 
contain but 20 or 30 per cent, of the normal amount of lime^ salts. 

2. General Symptoms. — a Muscular weakness is pronounced, as 
evidenced by impaired breathing, the tardy efforts to hold up the head, 
and disinclination to walk. h < Xutrition is usually poor: there is 
ana?mia, sometimes with leukocytosis and often with emaciation: the 
irritability and sweats have been mentioned under prodromes, (c) 
The nervous system is affected. Mentality is unimpaired. Rickets 
patients frequently grind their teeth. Spasmodic conditions are not 
infrequent, as generalized convulsions, tetany and spasm of the glottis, 
all of which will receive separate consideration. d • Temperature 
is not symptomatic of rickets and always denotes complications. 
Digestive disturbances are common; there may be anorexia, diarrhoea 
without pain or tenesmus, more commonly constipation and distention 
of the abdomen which can occur without anv digestive disorder, from 
enlargement of the liver and spleen, and possibly from thejthoracic 
changes. The amount of chalk in the faeces may be increased Bagin- 
sky . The spleen is enlarged in 70 per cent., and, less often and less 
markedly, the fiver. / Rickety children catch cold easily and bron- 
chitis frequently leads to atelectasis and bronchopneumonia, g) The 
heart may be luxated from the altered thoracic conformation, which 
also frequently causes hypertrophy of the right ventricle. h) The 
urine remains normal, the alleged increase in calcium and phosphorus 
salts being quite inconstant. £) Eczema is common. 

Courser Complications, and Prognosis.— a; The onset is insidious 
and the clinical course covers a year or more. b Complications 
include but few of immediate danger, as bronchitis, pneumonia, and 
spasm of the glottis which may result fatally. Later complications 
include the contracted rhachitic pelvis, which is of obstetrical import- 
ance, kyphosis and pulmonary tuberculosis, which is found in 36 per 
cent, of the fatal cases, sometimes with abdominal complications 
(tabes mesaraica s : its early diagnosis depends almost entirely upon 
auscultation, for percussion is peculiarly deceptive when the chest is 



RICKETS 935 

deformed, (c) The prognosis is, with these exceptions, excellent as 
to life, and with care, as to deformity, for many protuberances and 
deformities may regress. 

Diagnosis. — The diagnosis is based chiefly, — and then with cer- 
tainty — upon the changes in the skull and skeleton. Errors are easily 
possible from precipitate diagnosis, based on the purely prodromal 
phenomena, but otherwise confusion is rarely serious, (a) Barlow's 
disease (q.v.), which is misnamed acute rickets, has no connection 
with it. (6) Syphilis predisposes to rickets but is otherwise distinct 
and separate; it usually develops at a time (first to sixth month) 
when rickets is most uncommon, and is usually stamped by other 
syphilitic stigmata, as cutaneous and mucous syphilides; when it 
invades the epiphyses, the femur is usually its seat, and there may be, 
between the cartilage and bone, a wall-like, very tender, painful and 
usually doughy swelling which also is rather fusiform, compared with 
the rounder rhachitic nodes; epiphyseolysis with great dislocation of 
the fragments, may occur in syphilis, but never in rickets; in doubt- 
ful cases an ex juvantibus diagnosis may be made, (c) Vertebral 
tuberculosis (q. v. and also compression of the cord) is easily dis- 
tinguished; the rhachitic kyphosis is arcuate, not angular; other 
symptoms of either disease are almost invariably present, id) Hydro- 
cephalus {q.v., for differentiation). 

Treatment. — 1. Hygienic. — Fresh air and sunlight produce wonder- 
ful results particularly in the country, mountains or at the sea-side. 

2. Dietetic. — In nurslings (who seldom develop the disease) or in 
quite young babies, the use of a wet-nurse may entirely cure the 
disease. In other children it may be less a question of food than of 
digestion, which may require pepsin, taka-diastase, nux vomica, or 
hypophosphites. 

3. Medicinal. — No specific remedy is known, but the results pro- 
duced by phosphorus make it more important than any other drug. 
Under its use the child becomes easier and brighter; the nervous 
symptoms abate, as the insomnia, convulsions, tetany, or laryngospasm ; 
the osseous symptoms are improved, bone is deposited and dentition 
occurs, though less obviously in clinical experience than in animal 
experiments in which it seems certain that small doses stimulate bone 
formation directly and rapidly. Phosphorus itself is given in doses 
of gr. mh) to too in pill form, or as the ol. phosphoratum (1 per 
cent, solution) ttjtj, t.i.d.; the oil or emulsion should be freshly pre- 
pared, for both degenerate readily on exposure to light. (Its toxic 
symptoms are malaise, fever, thirst, anorexia, and weakness ; vomiting 
of food, mucus, bile, later blood and sometimes phosphorescent 
material may occur; there may be abdominal pains, diarrhoea or 
constipation, phosphorescent, clay-colored or bloody faeces; jaundice 
may develop; the liver at first may be large, but becomes small; there 
may be cholsemia; albumin, bile, casts, leucin and tyrosin in the 
urine and hemorrhages from the uterus, abortion or miscarriage and 
bleeding from other surfaces.) Cod-liver oil was recommended by 



936 CONSTITUTIONAL DISEASES 

Bretonneau in 1827; it carries out Cheadle's theory that animal fats 
and proteids are essential, and comforms with Sutton's experiences 
(v. $.). If it is well tolerated by the stomach, the general level of health 
may be elevated by its use; if not, cream and butter should be given. 
Iron (syr. ferri iodid.) is a good tonic. Calcium salts are now less 
used than formerly, as it has been proven that a sufficient quantity 
is present in the food and is absorbed. 

4. Orthopedic. — During the florid stage the child should be kept 
quiet upon a firm mattress. He should be kept off his feet. Later, 
corrective measures are indicated for the kyphosis and deformity of 
the limbs. Mikulicz holds that the apparently monosymptomatic genu 
valgum adolescentium is only a rhachitis tarda, and that genu valgum 
and varum should always be treated with rest, cod-liver oil and phos- 
phorus. 

(F). OBESITY. 

Etiology. — Obesity (adiposity, corpulence or polysarcia adiposa) 
is favored (a) by heredity; it frequently occurs in entire families ; 
congenital cases are known; (b) by mode of life; lack of exercise, over- 
eating and alcoholic indulgence, are potent factors, (c) The meno- 
pause is frequently attended by increase in weight, (d) Various 
diseases may cause it, as those of the nervous or osseous system, 
making exercise impossible; and gout, diabetes, various anaemias, 
chronic valvular disease, and emphysema, which act rather by pre- 
venting adequate exercise than by deficient oxygenation or from the 
condition of the blood. Adipose tissue may develop from tissue 
albumin. 

Symptoms. — The general habitus requires no description. Fat 
develops in the subcutaneous tissues, in parts where it is normally 
found, as in the omentum and around the kidney, and it may cause 
fatty infiltration and degeneration of all internal organs excepting the 
brain and spleen; even the blood may contain fat (lipsemia). 

1. Cardiac Symptoms. — The heart is embarrassed by increased 
resistance to the capillary flow, by the fatty infiltration (and degen- 
eration) of the myocardium, and by fat accumulation in the chest 
wall, omentum and mediastinum. The pulse is more often frequent 
than slow, though cases of bradycardia are noticed (see Stokes' triad 
under Fatty Heart) . Cardiac hypertrophy may occur. (Edema is not 
uncommon. 

2. Respiratory Symptoms. — The breath sounds and heart tones are 
faint, and thoracic percussion is difficult because of the subcutaneous 
fat. Bronchitis is common and probably results from the ready 
sweats and consequent chilling. Dyspnoea may occur on exertion 
only, or may develop from pulmonary oedema. 

3. Digestive Symptoms. — Digestive disturbances may develop. The 
large liver is less frequently fatty than congested and hypertrophic. 
Constipation and hemorrhoids are frequent. 



OBESITY 937 

4. The Urine. — The urine may be scant in comparison with the 
fluids ingested; coincident oxaluria, lipuria, lithuria, albuminuria or 
glycosuria may be noticed. Actual impotence is not uncommon, as 
well as mechanical obstacles to coitus. 

Two other groups of symptoms mark extreme obesity, viz.: (5) 
lessened 'physiological resistance to infections, as typhoid or pneumonia 
and to surgical measures or phlebotomy, and (6) such complications 
or associated affections as diabetes, gout, calculous disease and less 
often contracted kidney, arteriosclerosis, and apoplexy. Somnolence 
may be marked. 

Treatment. — Treatment is (a) that of the fundamental condition, 
as gout or diabetes, and (b) dietetic. Various "cures" have been 
formulated which are enumerated because they possess more than 
historical interest — (i) Banting's cure. Banting, a merchant, was 
treated so successfully by Wm. Harvey for obesity that he addressed 
a "Letter to the Public on Obesity" (1863). This diet was largely 
albuminous, and consisted of fish, meat, eggs, tea without sugar or 
milk, vegetables, fruit, some red wine, and toast without butter. This 
diet may cause indigestion, nervousness, insomnia, palpitation or gout, 
(ii) Ebstein, himself a sufferer, proposed (1872) a diet with larger 
proportions of fat; his diet consisted of meat, fish, eggs, tea, legumin- 
ous vegetables, fruit, fats and butter, but restricted the carbohydrates; 
digestive disorders may also occur under this system, (c) Oertel 
allowed more carbohydrates, limited the fats and fluids, and insisted 
upon sweats and graduated exercises. From the following it will be 
seen that all these methods are "starvation cures," with restriction 
of water in Oertel's method. The average man requires 118 gm. 
(45) of nitrogen, 56 gm. (2g) of fat, and 500 gm. (175) of carbo- 
hydrates (Voigt and Pettenkofer), equaling 3,054 calories. 

The diet of Banting contains 172 gm. (5.75) of nitrogen, 8 gm. 
(25) of fat, and 81 gm. (2.75) of carbohydrates, equaling 1,112 
calories. 

The diet of Ebstein contains 102 gm. (2.35) of nitrogen, 85 gm. 
(25) of fat, and 47 gm. (1.65) of carbohydrates, equaling 1,401 
calories. 

The diet of Oertel contains 183 gm. (65) of nitrogen, 38 gm. (1.35) 
of fat, and 143 gm. (4.85) of carbohydrates, equaling 1,690 calories. 
(A calorie is the temperature required to raise 1,000 gm. water, 1° C; 
a gram of albumin equals 3.2 calories, of fat 8.4, and of carbohydrates 
3.8 calories.) 

Banting's method supplies to the b^dy about 33 per cent, of the 
heat and energy normally required; Ebstein's less than 50 per cent, 
and Oertel's slightly more than 50 per cent. The lesson taught then 
is moderation in eating (v. Gout). In any reduction-cure the patient 
may suffer from breaking down of the body proteids, which causes the 
weakness that is experienced. In all cases the total amount of nitrogen 
in the urine, which constitutes 90 per cent, of the nitrogen excreted, 
should be watched; if more is excreted than ingested the nitrogenous 



938 CONSTITUTIONAL DISEASES 

food should be increased to obviate weakness, both muscular and 
cardiac. The diet then should consist, as in gout, of moderation in 
all foods, with restriction of the carbohydrates, whose easy reduction 
into water and carbonic acid spares the tissue waste. The fluid in- 
gested should be measured, and with due individualization, should be 
reduced to 2 or 3 pints daily. Alcohol should be forbidden, as it is a 
carbohydrate. Beer contains not only 3 to 5 per cent, of alcohol, but 
sometimes double this percentage of soluble starch and dextrine. 

(c) Active and graduated exercise is indispensable, except in cases of 
marked cardiac disease. It should be regular, induce sweating, and 
bring all muscles into play, but should not cause exhaustion. Passive 
movements (v. Fatty Heart, Myocarditis and Dilatation), and 
massage are indicated when active exercise is contra-indicated. 

(d) The patient should sleep not more than seven hours, and should 
bathe daily to avoid skin complications and to promote perspiration. 
Thyroid extract is not to be taken, except perhaps under special indica- 
tions, for it breaks down the albumins rather than the fats, often 
excites the heart, sometimes induces glycosuria and is wholly super- 
fluous (with proper dietetics and exercise). 



(G). ADIPOSIS DOLOROSA OR DERCUM'S DISEASE. 

This affection was described by Dercum (1892), as a "disorder 
characterized by unequal symmetrical deposits of fatty masses in 
various parts of the body, preceded or attended by pain." There 
were only 31 reported cases up to 1904, most of which were females. 
It usually develops in middle life, chiefly after the fortieth year, though 
the author has a case under treatment, aged thirty-five years. 

Pathology. — Its pathology is not yet developed, as but five autopsies 
have been made (1903). In the cases of Dercum and Burr, an inter- 
stitial neuritis was found, which is likewise noted in the fatty tumors 
which have been removed during life. It is interesting to note that 
symmetrical lipomatosis has been observed in multiple neuritis. In 
Dercum's and Burr's cases the thyroid gland was atrophied. Adeno- 
carcinoma and gliosis of the hypophysis have been reported. 

Symptoms. — Two cardinal clinical features are observed, as the 
term adiposis dolorosa indicates; (1) the obesity is either diffuse or 
may be localized fatty tumors, or sometimes both in combination; 
lipomata occur on the trunk and proximal parts of the extremities, 
but never on the face, forearms, hands, legs, or feet. Indeed the thin- 
ness of the wrists and legs contrasts sharply with the massive body, 
thighs, and upper arms. The fatty tumors range from the size of a 
pea to large dimensions. The pendulous abdominal fat may hang 
down like an apron. In one of the author's cases the localized abdom- 
inal fat was disposed in the shape of a circular life-buoy, sagging 
down over the thighs. In another it almost resembled oedema or 



ADIPOSIS DOLOROSA OR DERCUM'S DISEASE 939 

myxcedema, save for its circumscribed distribution and facial exemp- 
tion. 

2. The pains may be neuralgic or paresthetic. The trunk is often 
tender. 

Subcutaneous hemorrhages, hsematemesis, epistaxis and metrorrhagia 
are not uncommon. The patients are often nervous, perhaps hysterical. 
Asthenia is common, and subjects often lack initiative and readily 
tire on exertion. In the later stages epilepsy has developed, and death 
from asthenia, psychosis, nephritis or intercurrent affections is re- 
corded. A number of cases, including one of the author, have im- 
proved under administration of thyroid extract. 



SECTION IX 



DISEASES OF THE NEKVOUS SYSTEM 



DISEASES OF THE BEAIN. 

(A). CEREBRAL LOCALIZATION. 

The anatomy and physiology of the brain are most important in 
topical diagnosis. Autopsy findings in carefully studied cases, animal 
experimentation, and the constantly increasing surgical intervention, 
have developed not merely the nature of lesions, but also important 
results regarding their localization. The old doctrine of Flourens that 
all parts of the brain were equally important, met its first contradiction 
in Broca's discovery (1861), that motor aphasia was due to disease 
of the third left frontal convolution. In 1870, Fritsch and Hitzig dis- 
covered that stimulation of certain areas, now known as the motor 
cortex, invariably resulted in contraction of definite muscles of the 
opposite side of the body. Since then, Bevor, Horsley, Meynert, 
Jackson, Flechsig, Ferrier, Munk, Glotz, Nothnagel, Charcot, Wer- 
nicke, and others, have contributed to the development of brain locali- 
zation, although much still remains unclear and tentative. 

I. The Motor Cortex. 

This embraces chiefly the central convolutions on either side of the 
fissure of Rolando (the ascending frontal and ascending parietal lobes 
and anterior two-thirds of the superior parietal lobe), the foot of the 
three frontal convolutions, especially the lower, and on the inner sur- 
face of the hemisphere, the paracentral lobule. In this area lie the 

941 



942 



DISEASES OF THE NERVOUS SYSTEM 



large pyramidal cells which Betz discovered were the origin of the 
motor or pyramidal tracts. The centres are not sharply marked, but 
run somewhat into adjacent areas, especially those with physiological 
associations. The leg centre occupies the upper quarter of the ascend- 
ing frontal and ascending parietal convolutions, and part of the superior 
parietal lobe (all adjacent to the longitudinal fissure), and passes over 
to the inner aspect of the hemisphere to the paracentral lobule, which 
is the centre for the thigh, pelvis, and gluteal muscles (Fig. 51). A 
lesion in the falx cerebri, or dura near the longitudinal fissure may, in 

Fig. 50. 




General distribution of centres in cerebral localization ; outer surface of brain. 

rare cases, involve both paracentral leg centres, and produce cerebral 
paraplegia, although most paraplegias are spinal in origin. The arm 
centre is the largest, covers the middle two quarters of the central con- 
volutions, lies below and probably somewhat overlaps the leg centre. 
In Fig. 52, it is seen that there are certain general as well as separate 
centres for the thumb and fingers. The head centre is below that of the 
arm, covering the lowest quarter of the central convolutions (i.e., the 
entire operculum), the upper part of the Sylvian fissure, and the pos- 
terior part of the lowest frontal convolution (and possibly the first and 
second frontal gyri). The face centre lies directly beneath the arm 
centre, and is mostly located on the anterior ascending convolution, 
the upper facial component lying higher than the lower facial centres. 
The eye centre of the facial is bilateral, and probably consists of several 
foci. The mouth apparently has several centres. The motor speech 



THE MOTOR CORTEX 



943 



area is principally in the lower left frontal gyrus, and is probably the 
chief centre for chewing. The trunk centre is less clearly defined; it 
probably lies in the posterior part of the first frontal convolution, and 
also on its median aspect, just anterior to the paracentral lobule. The 
more complicated the function, the larger is the centre (as for the tongue, 
fingers, mouth), and the more unilateral the localization in the brain. 
Muscles used rhythmically, or in pairs, are supplied to some extent 



Fig. 51. 




Cerebral localization ; inner surface of hemisphere. 

from both hemispheres, as the muscles of the forehead, and of respira- 
tion, swallowing, chewing, vocal cords, and to some degree, of the legs 
and trunk. Protrusion of the tongue to one side has a monolateral 
centre, though its protrusion in the median line and its withdrawal 
depend on both hemispheres. 

Total lasting hemiplegia of the opposite side of the body, with sensory 
disturbance, aphasia, and intellectual disturbance, results from com- 
plete destruction of the entire motor cortex of one side. Cortical hemi- 
plegia is less common than monoplegia, which results from partial 
cortical foci. Monoplegia (paralysis of one member, as of the arm 
alone), always suggests, but does not absolutely prove, the presence of 
a cortical lesion. The paralyzed limbs are flaccid, and later undergo 
contractures. Pure monoplegias of cortical origin are rare, although 
the arm or leg may be paralyzed alone from a small softening, hemor- 
rhage, cyst, or tumor, or from traumatism. Crural (leg) monoplegia 
is rare (few instances being reported by French writers), and is due 
largely to vascular lesions in the paracentral lobule (anterior cerebral 
artery). Some sensory disturbance may be noted. Pure brachial 
(arm) monoplegia may result from vascular lesions, small tumors or 
trauma; complex movements as writing are most involved. The 
finest differentiation or selection, as of the thumb alone, fingers, or 



944 



DISEASES OF THE NERVOUS SYSTEM 



wrist, is noted in this form. Sensory disturbance is common (v.i.). 
Pure facial monoplegia is unknown, although a faciolingual form 
with motor aphasia is observed. Associated monoplegia is more usual. 
It consists most commonly of paralysis or paresis (partial paralysis) 
of the arm and face (brachiofacial monoplegia, passing under this 
name, although not strictly a monoplegia). Next in frequency is the 
arm-and-leg type (brachiocrural) in which two contiguous centres 
are involved. A leg-and-face type never occurs, because their centres 
lie too far apart. A lesion involving one cortical area after another 
speaks for cortical localization. Cortical paralyses are not attended 
by the reaction of degeneration. In cortical lesions with paralysis, 
twitchings or convulsive movements are common, and, from their 
resemblance to epileptic convulsions, are called "cortical, partial, or 
Jacksonian epilepsy"; 50 per cent, of cases are small cortical tumors 



Fig. 52. 



HEAD TO OPPOSITE SIDE 



HEAD AND EYES TO 
OPPOSITE SIDES 



TO MID LINE 
CHEWING 



ASSOCIATED 
MOVEMENTS 
YES 




Fl 



FINGERS_ALONE 
THUMB ALONE 



FISSURE OF ROLANDO 
A' FISSURE OF SYLVIUS 

Cerebral localization in detail. 

F 2 , F 3 , first, second and third frontal convolutions. AF, ascending frontal convolution and 
AP, ascending parietal convolution. SP, supramarginal and AR, angular convolution. Oi, 
Oo. O3, first, second and third occipital convolutions. Ti, To, T3, first, second and third tem- 
poral convolutions. The explanation of line AA is given under INTERNAL CAPSULE. 



or cysts; the lesion partly destroys the motor cortex (paralysis), and at 
the same time causes irritation (convulsions) precisely as contractions 
are produced in animals by electrical stimulation of the cortex; they 
are mainly (a) mechanical, as irritation or increased intracranial ten- 
sion (rapidly growing tumors), or (b) due to vascular affection (hemor- 
rhage, embolism, or inflammation). Stationary lesions rarely produce 
Jacksonian epilepsy, unless they are located in the cortex. The spasms 



THE MOTOR CORTEX 945 

may involve but one part, as the arm (monospasm), which is exclu- 
sively a sign of cortical irritation, or they may pass from one centre 
to others. They always commence in one centre locally, and extend 
in a fixed order. If the arm-region is the seat of a tumor, the Jack- 
sonian epilepsy flexes the fingers, moves the thumb, then the forearm, 
arm and shoulder, and then passes down the cortex region (see Fig. 50 
for leg, arm, face centres), so that it involves the face, mouth and 
finally the leg. If the lesion is in the face area, the various facial 
muscles contract, and the eye deviates, then the next area above the 
arm centre participates, and finally the higher leg centre is implicated. 
That is, the spasm never skips from the face to the leg centre, but it 
involves the arm first. If the leg area is involved, the spasms pass 
consecutively down to the arm and then to the face, i.e., they never 
skip the arm, nor involve the face before the arm is convulsed. 

The spasms are often preceded by a tingling in the part. The con- 
vulsions are mostly clonic, or clonic broken by tonic spasms, and 
consciousness is very often maintained. Unconsciousness may intervene 
when the fits reach the other side of the body, when the lesion is deep 
and below the cortex, or when they are very frequent, a hundred or 
more daily. The opposite side is involved through the commissural 
fibers of the corpus callosum; "bilateral representation in both hemi- 
spheres, which saves certain groups of muscles in hemiplegia, neces- 
sitates their involvement in severe spasms" (Gowers). Jacksonian 
differs from regular epilepsy in that no cry is observed, the commence- 
ment is local and more gradual, and consciousness, if lost, disappears 
gradually, not precipitately. The convulsions may precede or accom- 
pany the paralysis. The seizure lasts several seconds to a minute or 
two, and is followed by some vertigo, nausea, stupor, or disturbance of 
speech; if spasms occur without paralysis, paresis in the involved parts 
follows, due to transient exhaustion of the cortex. Jacksonian epi- 
lepsy in its lightest forms may be sensory. 

Regarding sensory localization in the cortex, opinions vary, and our 
knowledge is far less exact. Munk holds that the sensory and motor 
areas are the same, while Charcot, Nothnagel, and Ferrier hold that 
the sensory areas are separate (v.i.). Some vasomotor disturbance 
is common in cortical lesions, and Landois and Eulenberg have demon- 
strated a vasomotor centre here. 

Sequences of disease in the motor centres depend on the nature and 
extent of the lesion. After total lesions of the central convolutions, the 
hands improve very little in adults; other members improve, to some 
extent at least, through assumption of function by the sound side of 
the brain; in young individuals, the sound pyramidal tracts in the 
cord may hypertrophy to even double their original size. The motor 
fibers running from the pyramidal cells of the cortex to the anterior 
horns of the spinal cord, constituting the upper motor neuron, undergo 
descending degeneration, that is, degeneration in the direction of the 
motor impulse. 



946 DISEASES OF THE NERVOUS SYSTEM 



II. Cortex of the Parietal Lobes. 

Our knowledge of the function of this cortex is less definite than 
that of the motor cortex, (a) Lesions of the first lobe (Pj Fig. 52, 
the Precuneus in Fig. 51), supplied by the anterior cerebral artery, 
cause disturbance in motility of the leg, with altered muscle sense, 
"mind blindness," inability to read (alexia), and according to some 
authorities, hemianopsia, (b) Disease of the swpramarginal convolu- 
tion (S.P. Fig. 52), also involving the motor cortex, produces greater 
disturbance of sensation than when the lesion is confined to the motor 
centres ; muscular sense is disturbed, usually with some motor paralysis 
or paresis. Three cases are reported in which' there was disturbance 
of muscle sense without paresis. Muscle sense is disturbed in 23 per 
cent, of all cases of cerebral hemiplegia, though in more than 50 per 
cent, of cerebral paralyses, no special sensory disturbance is noted. 
Disturbance in muscle sense probably indicates that a cerebral lesion 
is located in the cortex, if indirect pressure can be excluded. There 
may be loss of the stereognostic sense, whereby the patient fails, when 
his eyes are closed, to recognize the geometric form of solid objects, 
as a key or ball. Cortical incoordination (ataxia) sometimes results, 
probably on account of disturbance in the association fibers. It differs 
from other ataxias (the tabetic and cerebellar forms), in that the mus- 
cular strength is usually diminished, and the finer movements are 
impossible, though the coarser movements may sometimes be carried 
out. Cortical hemianesthesia is not frequent, (c) Ptosis and paralysis 
of the orbicularis oculi are said to result from lesions of the gyrus angu- 
laris (A.R. Fig. 52), and according to Monakow, inability to read 
(alexia), optic aphasia and "mind blindness." Wernicke correctly 
diagnosticated softening in this lobe by conjugate deviation of the eyes 
and head as the only symptom. Disease of the posterior inferior part 
probably causes crossed amblyopia. 

III. The Cortex of the Occipital Lobes. 

This is undoubtedly the visual centre. Its exact seat is somewhat 
disputed, but the weight of evidence shows that it is in the cuneus 
(Fig. 52) and the first occipital lobe. A lesion of the occipital cortex 
produces (a) bilateral homonymous hemiopia (hemianopsia), (for details 
of which and the following see Affections of the Optic Nerve). 
(b) Hemichromatopsia, an homonymous color blindness, especially for 
green and red, in which the color perceptions are confused rather than 
lost; the lesion in such cases is superficial and anterior; (c) total cor- 
tical blindness, if the lesion is bilateral, or both optic radiations are 
destroyed, (d) " Mind blindness" results from a lesion on the anterior 
outer surface of the left occipital region, especially the second occipital 
lobe or (according to others) from disease of the gyrus angularis. 



THE FRONTAL CORTEX AND APHASIA 947 

The visual memory is lost; things actually seen are misinterpreted, 
and the patient confuses persons and things, (e) Alexia, inability to 
read, also called "word blindness," wherein the patient can read but 
fails to understand the letters or words he sees and reads. His memory 
for words is lost. It is due to destruction of the subcortical long and 
short association fibers in the second occipital lobe (von Monakow) 
and the gyrus angularis; it most commonly follows vascular disease. 
(/) Optic aphasia results from foci in the left occipital lobes (and also 
in the angular and supramarginal convolutions), and consists of mis- 
interpretation of visual impressions, so that the patient miswrites and 
misnames objects seen, though able to name them when he feels them. 
(g) Crossed amblyopia sometimes occurs. 



IV. The Cortex of the Temporal Lobes (T lf T 2 , T 3> Fig. 52). 

The outer surface of the posterior half of the first (and second) tem- 
poral convolution is the auditory centre; it is said to be larger on the 
left side; disease in this cortex produces (a) deafness in the opposite 
ear; atrophy of this lobe is encountered in congenital deafness. Deaf- 
ness is usually transitory, because fibers seemingly pass to both ears 
from each centre. If this lobe is destroyed on both sides, total deafness 
results. (6) Conjugate deviation of the eyes has been observed, and is 
said to be a reflex from auditory impressions, (c) Disease of the first 
temporal lobe produces "word deafness" also known as "mind deaf- 
ness" ; it is a loss of the comprehension of speech. Somewhat in front 
of this lobe, it is supposed that musical memories are stored. In the 
uncinate gyrus (Fig. 51) the special sense of smell probably has its 
centre. Ferrier refers the general sensory centre to this lobe. The 
gyrus fornicatus (Fig. 51) is said to be the centre for taste, and pos- 
sibly for the sense of pain. 



V. The Frontal Cortex and Aphasia. 

Regarding the frontal lobes anterior to their participation in the 
motor cortex, we have little definite knowledge. Profound disease 
may develop without clinical symptoms. They have long been thought 
to be the residence of (a) the psychical functions, especially for ethical 
and abstract thought (Meynert, and Flechsig). "Defect in character" 
followed the passage of a large crowbar, 1^ inches thick and 3J feet 
long, through both frontal hemispheres, in the famous crowbar case 
of Harlow. Psychical functions probably concern the frontal lobes, 
although the relative integrity of the entire brain is necessary for them. 
(b) Flechsig considers the frontal lobe the anterior association centre, 
the middle one being the cortex of the island of Reil, and the posterior 
one the large area posterior to the motor cortex, (c) Brims has observed 
ataxia similar to the cerebellar type, but this probably results either 



948 DISEASES OF THE NERVOUS SYSTEM 

from pressure transmitted to the cerebellum, or from involvement of 
the trunk centre, (d) The motor speech area lies in the lower frontal 
convolution. Its function and relations can be well considered in con- 
nection with motor and other varieties of aphasia. The history of 
aphasia marks the beginning of cerebral localization, and three French 
writers have determined its motor centre. Bouillaud, in 1825, referred 
aphasia to the frontal lobes; Dax, in 1836, narrowed the localization 
to the left frontal region, and the motor centre was finally confined to 
the posterior part of the lower left frontal convolution, in 1861, by 
Broca, whose name is given to this convolution. The sensory element, 
necessary to all voluntary movements, was unknown until later, when 
Meynert and Wernicke discovered the auditory centre in the first tem- 
poral convolution; Wernicke localized "word deafness" in the same 
convolution of the left side, and Naunyn, and others, emphasized the 
importance of the gyrus angularis and adjacent parts of the occipital 
lobes in cases of disturbance of writing, visual aphasia, etc. 

Motor Aphasia. — The motor speech centre lies in Broca 's lobe, the 
posterior part of the left third frontal convolution; it controls the motor 
centres next described and retains the impressions or memories neces- 
sary to their exercise. The corresponding lobe on the right side has 
some function, being the actual centre in left-handed persons. It often 
assumes the functions of the left speech centres, after disease of the 
latter, especially in children. Articulate speech also depends upon 
the integrity of the lower part of the ascending frontal convolution of 
the motor cortex, in which lie the centres for the mouth, lips, tongue, 
jaw, and larynx, (a) These constitute the cerebral mechanism of speech, 
whose disturbance is designated motor aphasia. Motor fibers run 
from the cortex through the centrum ovale, internal capsule (lying in 
front of the pyramidal tracts), crus (inside the pyramidal tracts) to 
their nuclei in the pons and medulla, whence the peripheral bulbar 
nerves to the tongue and larynx take their origin, (b) These lower 
tracts constitute the bulbar mechanism of speech, disease in the com- 
ponents of which causes abolition of articulation (anarthria), or more 
often imperfect articulation (dysarthria). The elements of speech 
are correct in dysarthria, but articulation is imperfect, for the labials, 
palatals, or Unguals are imperfectly delivered, or consonants are run 
together. To speak, the individual must have ideas, conceptions. 
To illustrate, a cortical lesion in Broca 's convolution, as small as a 
hazel-nut, may produce motor aphasia, which is either absolute or 
partial; the patient may pronounce correctly some few words, pos- 
sibly only under emotion or in certain relations, or he may pronounce 
words wrongly formed, although he recognizes his mistakes. He com- 
prehends what is said to him, for the lesion involves no special sense 
element. He can read writing and print, especially if educated, because 
" sight may stimulate images without intervention of the motor centre," 
but he cannot speak voluntarily, nor repeat what is said to him; he 
cannot read aloud ; he cannot write (agraphia) as a rule, because im- 



THE FRONTAL CORTEX AND APHASIA 949 

pulses cannot pass to the hand centre. He may be able to copy (v. i. 
Table). The cortical is the usual form of motor aphasia. 

A subcortical lesion in the centrum ovale may sever the fibers between 
Broca's convolution, and the motor cortex for the tongue, lips, 
etc. The patient cannot speak, but the speech centre is normal. It is 
a rare lesion, and is known as pure motor aphasia (Lichtheim). The 
patient can write. It involves the commisural fibers by way of the 
corpus callosum to the right side, and usually produces permanent 
aphasia, because the possibility of compensation by the right hemi- 
sphere is precluded, but if the lesion is in the internal capsule, the 
aphasia is transient, since compensation through the corpus callosum 
is established. 

Sensory Aphasia. — In speech, as in every voluntary motion, sensa- 
tion and sensory memories are necessary. The sensory relations of 
speech are hearing, sight, taste, and in the blind, touch. 

Auditory Aphasia. — Hearing is most important, and develops in 
the child long before speech. When a child begins to talk, or when one 
who has lost speech relearns it, the brain cortex, through an association 
of centres, learns to connect certain sounds or words with definite objects 
or conditions. The child hears through the auditory nerves which run 
from each side to both auditory centres in the first temporal convolution 
of either side. He hears mechanically, just as we may hear without 
understanding a foreign language, and learns to associate the sounds 
with objects, conditions or ideas, for which an auditory speech centre 
in the lefftfirst temporal convolution (in right-handed persons) is devel- 
oped. Here sounds coming from the two centres of hearing, are 
remembered, associated, and controlled. Remembering a sound he 
has heard, but perhaps has never spoken, the child calls into play 
Broca's convolution, the cortical centres for the lips, tongue, etc., and 
speaks. Hearing is necessary to articulate speech, unless, as in deaf 
mutes, education replaces, by sight and touch, the associations usually 
acquired by hearing. Destruction of the auditory speech centre pro- 
foundly disturbs speech. The patient then hears by the auditory 
nerves and centres, or reads by the visual apparatus, but does not 
understand what he hears or reads; this is known as sensory (auditory) 
aphasia, or word deafness. It is rarely absolute, and recovery is more 
common than in motor aphasia. The subject in speaking transposes 
words (paraphasia) but does not realize his mistakes, an important 
distinction from motor aphasia. Often he later becomes speechless. 
He cannot repeat words nor write from dictation. Voluntary revival 
of words is lost (Gowers). Voluntary writing is impossible, but copy- 
ing of words is sometimes maintained. 

Subcortical auditory aphasia, or pure word deafness (the rarer form), 
results from disease between the auditory speech centres and the two 
centres for hearing. It must therefore be below the cortex in the white 
matter, hence called subcortical. Auditory impressions cannot reach 
the auditory speech centres of the patient, who cannot understand 
what is said, cannot repeat or write from dictation. As the auditory 



950 DISEASES OF THE NERVOUS SYSTEM 

speech centre is normal, memory for words is retained, and the patient 
can read, speak, and write. 

" Amnestic" aphasia may be a simple difficulty in recalling certain 
words in speaking or writing, or it may be very pronounced (word 
deafness). It is also poorly called conduction aphasia (Wernicke), 
and is due to interruption, probably in the island of Reil, of the fibers 
between the motor and sensory speech centres. Gowers states that it 
may result from partial recovery from motor aphasia, or from sensory 
aphasia. 

Visual Aphasia. — Sight is very important in sensory speech. The 
child who has learned sounds (words) and is able to speak them, reads 
by associating the sounds heard and spoken, with words, letters, or 
symbols seen by him. Memory of these visual concepts is stored in the 
supramarginal and angular gyri. Reading music, etc., is learned in 
the same way. While in most individuals mental processes are carried 
on by the memory of words, in rare instances, visual memory may be 
more important. Destruction of the angular and supramarginal con- 
volutions by causing a loss of the visual memories, produces alexia, 
word blindness, an inability to read. In some cases, the patient can 
read, but without understanding. Isolated alexia is always due to 
lesions in these convolutions. He usually cannot write (agraphia), 
and cannot copy, but can speak fairly well and understand what is 
spoken. If the optic centre in the occipital lobes is intact, he cannot 
name objects after seeing them, since the visual memory centre is 
destroyed, but may recognize a watch by hearing it tick or by feeling it. 
Lesions just below the visual memory centre, involving the afferent 
fibers, produce pure subcortical word blindness, or alexia, that is, inabil- 
ity to read, with hemianopsia and preservation of voluntary speech 
and writing. Word deafness and word blindness often co-exist. Six- 
teen cases of congenital word blindness were collected by Stephanson 
(1904). 

Pure motor and sensory aphasia is less common than complicated 
forms. The diagrams often employed to illustrate the mechanism of 
aphasia are open to the objection that they are hypothetical, and do 
not cover all cases. The anatomical lesions, mostly arterial, are largely 
the result of softening, the entire sphere of speech or language being 
supplied by the artery of the fossa of Sylvius. Motor aphasia is likely 
to occur with disease of the motor cortex or cerebral pyramidal tracts, 
and the sensory form with disease of the optic fibers. Hemorrhage, 
trauma, and in children, tuberculosis of the brain or meninges, are also 
causative. Lasting aphasia in children is usually due to mental causes, 
since in early life the right frontal area usually takes up the function 
of Broca's convolution. Congenital aphasia may follow bilateral 
meningeal hemorrhage. Aphasia also occurs in idiocy in adults, in 
melancholia, migraine, convulsions, and is especially apt to occur 
from functional causes in children, as from fever, fright, worms, etc. 
In adults, the outlook is less favorable than in children. Partial 
recovery is possible in cases of hemiplegia, and sometimes with care, 



THE INTERNAL CAPSULE 951 

reeducation may yield fair results. The following table (on page 
952) is borrowed from Archibald Church's excellent work on Nervous 
Diseases. 

VI. Centrum Ovale. 

Lesions are usually hard to diagnosticate, and focal symptoms may 
be entirely absent, if a lesion occur between the associative, commis- 
sural, motor, or sensory fibers (corona radiata). When present, symp- 
toms are usually those of (a) a cortical, or (b) an internal capsule lesion. 
A lesion must be (a) very near the cortex to produce either Jacksonian 
or general convulsions. A monoplegia and subcortical aphasia may 
occur in this location. Sensory disturbances, as hemianopsia, may be 
noted in a subcortical disease. Aphasia from a lesion in the island of 
Reil may produce the so-called conduction aphasia. Psychical symp- 
toms may result from interruption near the centre of the association 
fibers which run from one part to another of the same hemisphere. 
(Commissural fibers are those running from one hemisphere to the 
other, as through the corpus callosum, disease of which presents no 
pathognomonic sign, according to most neurologists.) (b) Internal 
capsule symptoms result in lesions low in the centrum ovale. Hemi- 
anesthesia and sensory symptoms in general indicate lesions of the 
internal capsule. 

VII. The Internal Capsule. 

It is compacted and consists of nearly all the motor, sensory, and 
special sense fibers from the brain to the lower parts. It has an exten- 
sive vascular supply. The capsule is divided into an anterior limb, 
the knee and a posterior limb. 

Anterior Limb. — Its function is not clear, although it contains fibers 
from the frontal cortex to the optic thalamus. Lesions here are very rare. 
It also contains fibers which, in lower horizontal sections, run into the 
knee and are found in basal median bundle of the crus, whence they 
run to the pons nuclei for the eye, head, neck, and probably also for 
the larynx, tongue, and mouth. 

Knee. — The knee (see Fig. 53) contains from before backward 
fibers for opening of the eyes, associated movements of the eyes and 
head, the tongue and mouth; Horsley and Beevor have been able 
to stimulate them electrically, one by one. This segment contains the 
phonation fibers for speech, probably including those of the larynx. 

Posterior Limb. — The posterior limb contains in its anterior third, 
the fibers for the shoulder, elbow, wrist, fingers, thumb, and body; in 
its middle third those for the hip, ankle, knee, and toes; in its posterior 
third (Charcot's " sensory crossway"), those for sensation and the 
special senses. The number of fibers to a part depends less on the 
size of a muscle than on its development in fineness of movement ; for 
instance, the fingers receive a relatively large number of fibers. If a 



952 



DISEASES OF THE NERVOUS SYSTEM 












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953 



ruler be placed anterior to the line {A A) in Fig. 52, and slowly moved 
to the right, preserving its parallelism, it will be seen that the cortical 
motor areas touched will approximately correspond with their order 
in the internal capsule. The most common sequence of lesions of the 
internal capsule is cerebral hemiplegia of the opposite side of the body. 
Though hemiplegia may result from lesions elsewhere in the motor 
tract (cortex, centrum ovale, cms, pons, or medulla), in the vast 
majority of cases, hemiplegia is the result of disease of the internal 



Fig. 53. 




Localization in internal capsule. 



capsule. If the internal capsule is destroyed, total hemiplegia results, 
and paralysis of the arm, leg, and lower part of the face (the upper 
part of which, and the head escape, because they have a bilateral supply 
from both hemispheres). The hypoglossus is but moderately involved 
as a rule, and aphasia is usually temporary. With the hemiplegia are 
also associated hemianesthesia, hemianopsia, and unilateral disturb- 
ance of smell, taste, and hearing, by lesion of the fibers ascending from 
the tegmentum; with the hemiplegia are observed contractures, 4e- 
scending degeneration, decrease or absence of the skin reflexes, espe- 
cially the cremasteric, and increase of the tendon reflexes. Monoplegia 
is rare, because the tracts are so. compact that the face, for example, 
is rarely alone involved, though Duplay and Diday record isolated 
cases. It is possible that a linear lesion may involve the outer part of 
the capsule's knee, that is, it may involve the face and also the leg, 
leaving the arm free (Wernicke, Charcot, Kolisko). Hemiansesthesia 
(skin sensation and muscle sense), rarely exist without some paresis 
of the leg. Some tingling or, in incomplete lesions, some pain may 
result, even when the leg-arm areas are alone involved, for some sen- 



954 DISEASES OF THE NERVOUS SYSTEM 

sory fibers course with the motor fibers. Hemi-tremor, -athetosis and 
-chorea result from lesions of the sensory area, usually associated 
with disease in or just below the optic thalamus. (The course of the 
sensory paths will be considered under Localization in the Spinal 
Cord.) Back of the general sensory tracts, disease may injure the 
optic radiation (running between the occipital sight centre and the 
lateral geniculate body), or interrupt the auditory and other special 
sense fibers. Psychical disturbance, aphasia, alexia, agraphia, and 
permanent involvement of any cranial nerve are not symptomatic 
of disease of the internal capsule. 



VIII. The Corpus Striatum. 

This is composed of the caudate and lenticular nuclei. It is doubtful 
whether it is connected with the cortex. The lenticular nucleus is 
extensively connected with the superior peduncle of the cerebellum 
and the tegmentum of the crus. The caudate nucleus is connected 
with the internal capsule, and with the crus; these fibers seem to end 
in the pons and cerebellum. An apoplexy in the corpus striatum prob- 
ably causes rise of temperature ; Nothnagel 's law still holds that hemi- 
plegia is permanent only when the internal capsule is directly injured, 
although indirect transient hemiplegia, from simple pressure on the 
capsule, may result from disease of the corpus striatum. Landouzy 
reports a case of contralateral hemiathetosis from isolated disease of 
the lenticular nucleus. 



IX. The Optic Thalamus. 

This is surrounded by gray matter, continuous with that surround- 
ing the third ventricle and central canal of the cord, and is connected 
by fibers with all parts of the cerebral cortex, the tegmentum, and 
superior cerebellar peduncle. Nothnagel (1879) was the first to 
describe its topical symptomatology. Sometimes disease in this locality 
is latent; again, the following findings are observed, alone or in com- 
bination: (a) Contralateral hemianopsia may develop from a lesion 
in the posterior part of the thalamus, the pulvinar (Gowers), or a lesion 
which also invades the lateral geniculate bodies (von Monakow). 
These areas are connected by the optic radiation with the optic centre. 
This hemianopsia is distinguished from that caused by a cortical lesion 
by the hemianopsic pupillary reaction and the absence of the marginal 
field of vision, (b) Disturbance of the mimetic movements of expression 
may develop (Nothnagel, Bechterew). The optic thalamus is the reflex 
centre of the involuntary movements for expression, as weeping or 
laughing. A patient with hemiplegia from destruction of the left inter- 
nal capsule cannot voluntarily move the lower right part of the face, 
but the paralyzed portion of the face moves when the patient laughs, 



THE CORPORA QUADRIGEMINA 955 

for the centre is in the posterior part of the thalamus. On the other 
hand, in isolated disease of the optic thalamus, the opposite side — 
indeed both sides of the face, — can be voluntarily moved, since the 
facial nerve runs in the internal capsule, but the patient cannot laugh or 
weep, (c) Sensory disturbances may occur, such as hemianesthesia, 
hemichorea, hemitremor, pain in the opposite arm (Edinger), or hemi- 
ataxia, but it is not absolutely certain in some of these cases that the 
sensory portion of the internal capsule was not involved. There may 
be vasomotor changes, atrophy, and disturbance in the evacuation of 
the bladder and rectum. Von Monakow thinks that all the symptoms 
referred to the thalamus are probably referable to disease exterior to it. 



X. The Corpora Quadrigemina. 

These are masses of gray matter, whose fibers lie over the aqueduct 
of Sylvius and the tegmentum. There is much variance of opinion 
regarding their function. They are actually connected with the third 
nerve nucleus, and some hold that they contain the centres for con- 
traction of the heart and stomach. 

Disease in the anterior corpora quadrigemina produces (a) moderate 
involvement of sight. Some writers claim that total blindness or hemi- 
anopsia may result, but most of these cases had tumors with optic 
neuritis; slight disturbance has a greater localizing significance if there 
is no coincident neuritis. These bodies are connected with the external 
geniculate bodies and, by way of the internal capsule, with the optic 
radiation, (b) In acute lesions, narrowing of the pupil is suggestive 
of this localization. In old lesions, one or both pupils are wide, and 
without reaction to light or accommodation, (c) The eye muscles may 
be partially paralyzed, especially those supplied by the third nerve; 
this results in ptosis, and upward movements of the eyes. The dis- 
turbance is not associated. Much doubt is felt in considering these 
symptoms indicative of this localization, because the lesion is always 
so near the nucleus of the third nerve. Disease in the posterior corpora 
quadrigemina may result (a) in ataxia, according to Nothnagel, though 
others refer it to actual cerebellar disease, to connections with the cere- 
bellum through the nucleus ruber, or to disease in the fillet of the teg- 
mentum; (b) in trochlearis paralysis; in which the eyes cannot be 
turned inward or outward ; sometimes it results in abducens paralysis ; 
(c) in difficult mastication from involvement of the descending branch 
of the quintus; (d) in contralateral disturbance of hearing, since the 
posterior corpora quadrigemina are connected with the fillet of teg- 
mentum and, by means of the "sensory crossway" of the internal 
capsule, with the hearing centre in the first temporal lobe. 



956 



DISEASES OF THE NERVOUS SYSTEM 



XI. The Crus (Cerebral Peduncle). 

Focal symptoms may be divided into motor and sensory symptoms. 
The motor fibers to the cranial nerves decussate higher than the pyra- 
midal tracts which decussate in the medulla; the fibers to the third 
nerve cross in the upper crus, although some enter the nucleus of the 
same side. Crossed paralysis (hemiplegia alternans oculomotoria 
superior) is common in crus lesions. It consists of a hemiplegia of the 
side of the body opposite to the lesion, and a paralysis of the third nerve 
on the same side as the lesion, often known as Weber's paralysis, though 
it was first described by Gendrin. From Fig. 54, it is seen that a lesion 
involving the right pyramidal fibers may also catch those of the third 

Fig. 54. 




Lesion in crus (shown by dotted lines) , producing a superior alternating or crossed hemiplegia; the 
lesion involves the pyramidal tract (PR) , the cranial nerves (tongue and face, CR) and the 
ouclomotor nerve (III, F) which is paralyzed on the same side as the lesion while PR and CR 
are paralyzed on the opposite side. AS-Aqueduct of Sylvius; Ill-nucleus of third nerve; 
CGI-Corp. geniculatum int.; Fi-upper part and Fr-lower part of fillet; NR-nucleus ruber; 
SN-Substantia nigra. 

nerve on the same side, giving a left-sided hemiplegia (face, arm, and 
leg), and right-sided oculomotor paralysis, which is peripheral and 
usually complete, with strabismus, ptosis, inability to look up or down, 
and a wide reactionless pupil. The crossed or alternating hemiplegia 
is called superior to designate its location, because inferior alternating 
hemiplegia may also occur in lesions of the pons. One must be sure 
that one lesion only exists. In tumors near the internal capsule 
which press on the'third nerve, the same symptom complex may occur, 
and is recognized by noting whether the hemiplegia and paralysis of 
the third nerve occurred together (indicating a crus lesion) or whether 
the third nerve paralysis followed the hemiplegia (indicating a lesion 
near the internal capsule pressing secondarily on the oculomotorius). 



THE PONS 957 

A lesion in the tegmentum of the cms may cause (a) sensory disturb- 
ance, as hemianesthesia, which involves skin sensation and muscle 
sense, and of which over thirty cases are recorded; such a lesion is in 
the fillet; hypesthesia (reduced sensation) is more common, (b) The 
special senses are sometimes involved, producing hemianopsia, or poor 
hearing in the opposite ear. (c) Ataxia has been seen alone (6 cases), 
or together with other symptoms. It differs from the cerebellar type 
in that it is manifest only on motion. Involvement of the red nucleus 
(which is connected with the cerebellum or with its arm), produces 
cerebellar ataxia, (d) Oculomotor paresis on the side of lesion is char- 
acteristic when combined with crossed hemiataxia, hemiplegia, hemi- 
anesthesia, or possibly with tremor, low temperature, and vasomotor 
disorder. Fig. 54 shows how a tegmental focus can rarely miss the 
diffuse nuclei of the third nerve. If the lesion is in the lower part of 
the crus, the oculomotor paralysis is usually complete, but if in the 
tegmentum, it is always partial, selecting the pupil, the lid, or the 
superior or internal rectus muscles. 



XII. The Pons. 

Lesions of the pons are most commonly tumors, hemorrhage, soften- 
ing, or abscess. Its structures are so closely arranged that sometimes 
both sides are implicated, and this may produce bilateral hemiplegia, 
though a small lesion, as a long thin tumor, may give no localizing 
symptoms; most diseases of the pons produce a typical picture. From 
a lesion of the upper pons, i. e., the portion above the facial nucleus, a 
hemiplegia results like that produced by lesions of the internal capsule, 
which affects the face, arm, and leg, all on the same side of the body. 
(See Fig. 55, focus A.) The facial paralysis is supranuclear, partial, 
and with no reaction of degeneration. In a focus in the lower pons 
(focus B, Fig. 55), where the facial fibers have already crossed, 
the tongue, arm, and leg are hemiplegic on the side opposite to the 
focus, and the facial paralysis is on the side of the lesion; this is 
the crossed or alternating paralysis (hemiplegia alternans facialis), 
which was first described by Millard (1856), and then by Gubler 
(1859). The facial paralysis is peripheral and nuclear, involves all 
branches, and gives the reaction of degeneration. Sometimes there 
is also some slight paralysis of the face on the hemiplegic side from 
involvement of some fibers from the cortex. Other alternating par- 
alyses are also observed, as hemiplegia with crossed paralysis of the 
third, fourth, fifth, and sixth nerves, the paralysis of which is usually 
both central (nuclear) and peripheral. Hemiplegia may occur with 
conjugate paralysis or paresis of the lateral eye muscles, as the external 
rectus (abducens nerve) of one side, and the internal rectus (third 
nerve) of the other, due to a lesion just in front of the abducens centre, 
involving its fibers, or sometimes also including its nucleus. In the 
conjugate paralysis, the antagonist muscles pull the eyes to the other 



958 



DISEASES OF THE NERVOUS SYSTEM 



side, and the eyes look away from the side of the lesion, toward the par- 
alyzed side. This is not to be confused with the "forced position" of 
the eyes due to irritation, known as conjugate deviation, in which the 
eyes look to the sound side of the body. In this form even the paralyzed 
internal rectus will functionate and converge when one eye is tested 



Fig. 55. 




DECUSSATION OF PYRAMIDS 




A illustrates a lesion in the upper pons, producing the usual hemiplegia (face, arm and leg para- 
lyzed on the opposite side). B illustrates a lesion in the lower pons, producing alternating 
paralysis; all branches of the face (peripheral paralysis) and tongue on the side of lesion are 
paralyzed with paralysis of the contralateral arm and leg. 

at a time. In' some cases both internal recti and one abducens may be 
paralyzed, resulting in fixture of the eye in the median position ; accom- 
modation and convergence are preserved. Involvement of the motor 
branch of the fifth nerve produces difficult mastication. While alter- 
nating paralysis is the usual pons lesion, sometimes double hemiplegia 
occurs, or again, involvement of the third to seventh cranial nerves 
without an hemiplegia. The auditory nerve is rarely involved, save in 
acute or very extensive lesions affecting the lateral lemniscus. Impli- 
cation of the cortical fibers of the hypoglossus produces impaired move- 
ment of the tongue (dysarthria), nasal speech, and poor enunciation 
of consonants, especially Unguals and labials, though the vocal cords 
are normal. Dysarthria and dysphasia, due to disease of the cortical 
motor paths of the hypoglossus and vagus, are less common in lesions 
of the pons than are affections of their nuclei in diseases of the medulla 
oblongata. Ataxia may result from involvement of the fillet, and pos 
sibly of the longitudinal bundle of the formatio reticularis, and produces 
incoordination on voluntary movement only. An alternating sensory 



THE CEREBELLUM 959 

paralysis may occur, as (a) hemianesthesia involving the muscle sense, 
and cutaneous sensation of the extremities opposite the lesion, caused 
by disease of the tegmentum, and (6) an anaesthesia of the fifth nerve 
on the side of the lesion. Irritative symptoms sometimes develop, as 
pain, paresthesia, painful convulsions, which usually occur in acute 
cases, and which are peculiar in their involvement of both arms or 
both legs, tonic and clonic spasms in the opposite arm and leg, con- 
tractures, paroxysms of coughing, and trismus. The patient may 
"look toward the lesion" when the eye muscles are irritated. A 
tendency to fall toward the side on which the lesion is located, is indic- 
ative of disease of the middle peduncle of the cerebellum. It is some- 
times difficult to decide whether the focus is located in the pons or in 
the medulla. Though the topical symptoms of the medulla oblongata 
are described under its individual diseases, it may be stated that an 
alternating or crossed paralysis, involving the third to seventh nerves 
inclusive, indicates disease in the pons, and that aphonia, dysarthria, 
and dysphagia are symptomatic of localization in the medulla, especially 
when the hypoglossus is paralyzed, shows the reaction of degeneration, 
and produces atrophy of the tongue. Glycosuria, albuminuria, dis- 
turbed respiration or heart action (by involvement of the vagus), and 
vomiting are other bulbar symptoms. Disease in the medulla may 
cause paralysis of both arms and legs, or rarely of one arm and the 
opposite leg (this latter is known as hemiplegia cruciata) . 



XIII. The Cerebellum. 

Physiology — The functions of this organ are not fully known. 
Certain physiologists admit the possibility of some psychical function. 
Its sensory relations are important, because of its reception of numer- 
ous fibers from the spinal cord, including the direct cerebellar tract and 
the posterior median column of Goll. It is an "end organ" (Luciani) 
for these tracts, through which and its relations to the motor tracts 
and the special senses, it is supposed to coordinate and harmonize 
the movements of the body, to maintain equilibrium, conserve muscular 
strength and inhibit the contralateral cerebral motor cortex, In other 
words, it associates (a) the sensory impressions ascending from the spine 
with (b) those gained by hearing (the auditory nerve having connections 
with the middle cerebellar lobe), and (c) probably with those impres- 
sions resulting from the eye movements. 

General Pathology. — Disease of a lateral lobe affects the same side 
ofjthe body, but lesions of the middle (vermiform) lobe influence both 
sides. Results of extirpation in animals vary somewhat, and will be 
considered only from their clinical aspect. Krauss found, in 100 cases 
of cerebellar disease, tumors in nearly 80 per cent., abscess in 10 per 
cent., cysts in 7 per cent., and softening and hemorrhage constituted 
the balance. Agenesis, sclerosis, and gliomatosis are also occasionally 
found. Disease of one hemisphere, or indeed extensive lesions of both 



960 DISEASES OF THE NERVOUS SYSTEM 

hemispheres may be fully compensated by the cerebrum. Acute dis- 
ease of the cerebellum produces symptoms more frequently than does 
chronic disease, in which latter the cerebellum has opportunity for 
accommodative compensation. Rapidly growing tumors, abscess, 
and sometimes acute vascular disease often produce the following 
symptoms, in part typical, and in part secondary (general). 

Typical Symptoms. — 1. Cerebellar ataxia is almost always present, 
and occurs when the patient stands; equilibrium is disturbed, and the 
body sways; this is known as static ataxia. Ataxia also occurs when 
the patient moves (dynamic ataxia), and concerns especially the trunk 
and legs. The incoordination is due to disease of the middle lobe or 
vermis, and the consequent withdrawal from the cerebrum of the cere- 
bellar coordination. The gait is that of an inebriate (demarche d'iv- 
resse); the body sways and the individual stumbles a zig-zag course, 
and sometimes toward the side of the lesion. The arm and hand move- 
ments are usually normal. Ataxia may also result from lesions of the 
nerves, spine or brain (cerebellum, cerebral cortex, internal capsule and 
probably tegmentum). In the ataxia resulting from other cerebral 
localization, the incoordination affects the finer movements, i<? asso- 
ciated with disturbed muscle and stereognostic sense, and very often 
with paresis. Bouillaud first described cerebellar ataxia, and differ- 
entiated it from the tabetic type. The essential differences are (a) 
that in the cerebellar form the ataxia disappears when the patient is 
lying down, and (b) that closing the eyes does not increase it (indeed, 
it may often disappear). 

2. Vertigo is very frequent, and usually occurs rather when the 
patient sits than when he lies down. He thinks that objects are turn- 
ing around him, or he may feel himself being turned. The vertigo is 
either constant or paroxysmal, and is due to lesion of the vestibular 
nerve which connects the semilunar canals with the cerebellum by 
means of the corpus restiforme. 

Secondary Symptoms. — The following secondary symptoms are 
important but less significant than ataxia and vertigo : (a) Choked disk 
is rarely absent in cerebellar tumors, and amaurosis often results from 
increased pressure on the third ventricle, leading to hydrocephalus 
internus, and then to pressure on the chiasm or optic nerves. (6) 
"Forced" postures and movements are generally considered due to 
disease of the middle peduncle (crus cerebelli ad pontem). Forced pos- 
tures of the head and trunk are observed; one eye looks upward and 
inward, while the other is directed downward and outward. Forced 
movements consist of the turning of the patient constantly to one side, 
movement in a circle and a tendency to fall toward the side of lesion 
and sometimes backward, (c) Muscular weakness (asthenia) is frequent 
in animals (Luciani), and is occasional in man. A hemiparesis occurs 
on the side of lesion. The patient may not be able to rotate the trunk, 
to straighten the body after bending, or to get up after falling, (d) 
The patellar reflexes are usually normal or increased. Sometimes they 
are lost from pressure on distant structures, or from spinal disease. 



ANEMIA OF THE BRAIN 961 

(e) Vomiting and pain in the head or nape of the neck are frequent 
and of some localizing value. (/) Occasionally the following symptoms 
develop; nystagmus, rhythmical contractions of the head, convulsions, 
paralysis of the cerebral nerves from pressure on the midbrain, dis- 
turbed hearing, intention tremor, muscular rigidity, irritability, weak 
memory, and stupor. 

XIV. Medulla (See Diseases of Medulla Oblongata). 

(B). CIRCULATORY DISEASES OF THE BRAIN. 

I. Anaemia of the Brain. 

This term has been much confused and abused. The symptoma- 
tology of anaemia and hyperemia is so similar that differentiation is 
sometimes impossible. 

Etiology. — (a) General systemic- anaemia may result from chronic 
anaemia, cachexia, and hemorrhages of medical, surgical or obstetrical 
nature, (b) Decreasedblood supply, due to cardiac insufficiency, valvular 
stenosis, stenosis of the vessels by aneurysm or tumor, and puncture 
of pleurisy or ascites leading to paresis of the thoracic or abdominal 
vessels may be causal. It may also follow the evacuation of an enor- 
mously distended bladder or colon. Sometimes fasting seems to be a 
cause in individuals who faint when the stomach is long empty, (c) 
Capillary compression by hydrocephalus or tumors, but especially by 
cerebral hemorrhage, may produce anaemia. Sometimes venous hyper- 
aemia may act in the same way. (d) Local causes in the vessels will 
be considered under softening. Ligature or compression of one carotid 
produces symptoms only when the other vessel is atheromatous. 
Gerhardt induced convulsions by pressure on one carotid, and con- 
sidered it indicative of cerebral atheroma of the other cerebral vessels. 

Pathology. — The meninges, the cortex, and the white substance are 
pale, the brain is often firm and dry, and fewer puncta vasculosa are 
seen. The fluid in the ventricles is often increased. Geigel terms the 
slow capillary flow, " diamorrhysis. " 

Symptoms. — Local anaemia of the brain leads to imperfect function, 
then loss of function, and finally, to necrosis, as in embolism or throm- 
bosis (q.v.). General anaemia may be sudden or gradual in onset. 
In sudden anamia, as after hemorrhage or in fainting, the subject 
becomes drowsy, syncope occurs, and after return to consciousness, 
sight is impaired. Amaurosis is also frequent without syncope. There 
is ringing in the ears, and the pupils at first contract from irritation of 
the third nerve, and later dilate from its paralysis; this is a sign of 
danger. The skin is pale and clammy, the muscles are lax, and nausea 
is frequent. Epileptiform convulsions often occur when much blood 
is lost, and are probably due to irritative anaemia of the cortex, or pos- 

61 



962 DISEASES OF THE NERVOUS SYSTEM 

sibly of the pons or medulla. Anaemia of the medulla causes the slow, 
sighing respiration, and the frequent yawning. Death may follow 
syncope, and was called nervous apoplexy by the old writers. In 
gradually developing anaemia, as pernicious anaemia, the brain power 
is lessened, and irritability, delirium, insomnia, headache, vertigo, 
weak muscles, spots before the eyes, impaired sight, ringing in the ears, 
and sometimes deafness, may result. These symptoms are aggravated 
by sitting or standing, and are relieved on lying down. Palpitation and 
thoracic oppression are common symptoms. The pulse varies in rate 
and rhythm. Increased reflexes, paresthesia, and jerking of the muscles 
are frequent. Some mental symptoms usually remain after recovery. 

Marshall Hall has described hydrencephaloid, a variety of cerebral 
anaemia, which is seen in children suffering with acute diarrhoea, and 
is characterized by contracted and later dilated pupils, depressed font- 
anelles, sunken face, pallor, early irritation followed by stupor or even 
coma. It may resemble meningitis from the strabismus, rigidity of the 
neck, and convulsions. It is usually amenable to treatment. 

Treatment. — Treatment, as well as diagnosis and prognosis, is chiefly 
that of the cause. The anaemia is treated by putting the patient in the 
recumbent posture, and instituting rest in bed, iron, arsenic, a full 
diet, and sometimes small doses of opiates. Acute anaemia necessitates 
absolute rest, free stimulation, coffee by rectum, faradization of the 
chest and abdomen, and enemata or subcutaneous infusions of salt 
solution. Firm bandaging of the extremities, sometimes called auto- 
transfusion, is valuable. Rest and cardiac stimulation are indicated 
in cardiac cases. For hydrencephaloid, warmth, stimulation and fluids 
are necessary. Nitroglycerine is valuable in certain cases, which are 
possibly due to vasomotor spasm. 



II. Hyperemia of the Brain. 

Congestion of the brain is an obscure lesion. Andral (1836) de- 
scribed 8 varieties; and when Trousseau, in 1861, attempted to refer 
some varieties to epilepsy and Meniere's disease, he drew down upon 
him the wrath of the entire Academy. The hyperaemia which is de- 
scribed in nephritis is usually uraemic, and the collateral arterial fluxion 
once attributed to erysipelas is entirely toxaemic. Geigel has proposed 
the term "endiamorrhysis" for the normal flushing of the brain by 
its capillaries, which implies a normal metabolism and exchange of 
gases. The essential element is the rapidity of the capillary flow. 
When the vessels dilate from paralysis of the sympathetic system, the 
rapidity decreases, whence there is not hyperaemia of the brain, but 
rather a lessened capillary flow, adidmorrhesis. On the other hand, 
when the vessels contract from sympathetic irritation, the brain is not 
anaemic, but on the contrary, the capillary flow is accelerated, hyper- 
diamorrhysis. General arterial tension is not important, but the ten- 
sion of the vessel wall is the essential element (Geigel). 



HYPEREMIA OF THE BRAIN 963 

Etiology. — Hyperemia may result from active or passive conges- 
tion, though many doubts are entertained in regard to the older con- 
ception. The prevailing description may be adhered to, provisionally. 

Active congestion results (a) from cardiac overaction; (b) from over- 
filling of the brain vessels, when arterial blood cannot perfectly reach 
the lower parts, as in stenosis of the isthmus of the aorta; (c) from 
contraction of the arterioles in other parts; (d) from dilatation of the 
brain vessels by alcohol, nitroglycerine, coffee, exophthalmic goitre, 
excessive brain work, neurotic states, and insolation, (e) It may occur 
as the first stage of inflammation. (/) In plethoric men, with florid 
faces, thick neck, and short thorax, active congestion may cause certain 
passing brain symptoms. 

Passive congestion results (a) from general mechanical venous stasis, 
as in valvular heart lesions; and (6) from local venous stasis, as sinus 
thrombosis; according to GeigePs conception, it is held that venous 
stasis leads to capillary anaemia. 

Pathology. — The pathological findings are few, for congestion dis- 
appears after death; the brain may appear anaemic after death by 
strangulation (Ackermann and Jolly), and the head may become con- 
gested after death, because of its posture alone. The sinuses and veins 
are usually turgid and sometimes varicose, and the color of the brain 
is darker than normal. Microscopic examination shows distention of 
the capillaries, at times increased blood pigment, or actual rupture into 
the perivascular lymphatic sheaths, or into the brain substance. 

Symptoms. — No symptoms are characteristic. In active congestion, 
the symptoms vary with the cause; chronic cause fewer symptoms 
than acute factors. Whether toxsemic symptoms of the acute infections 
are due to hyperemia, is an open question; the headache in early 
typhoid has often responded to ergot in personal experience, and this 
may possibly be used as an argument. The retina has seldom been 
examined in such cases. Nothnagel and Gowers report cases with 
paroxysmal throbbing of the vessels, flushing of the face, headache, 
delirium, sometimes nausea and fever, which are relieved by nose- 
bleed and venesection; some describe similar symptoms from sup- 
pression of the menses, or of bleeding piles. Irritability, insomnia, 
spots before the eyes, ringing in the ears, and increased pulse are also 
said to occur. In progressive paralysis, the transient pyrexia, heat in 
the head, or coma, are referred to congestion of the brain. In middle 
and advanced life, the so-called congestive apoplexy has been noted, 
which consists of coma, sometimes with transient hemiplegia, though 
many cases are probably due to small hemorrhages, softening or dis- 
ease of the vessels. 

Passive congestion, if gradual in onset, may be well tolerated, or may 
produce stupor, dulness, or even delirium. If intermittent, as from 
coughing, the symptoms are a sense of fulness in the head, headache, 
and sometimes convulsions; these are increased by exertion, by the 
patient lying in the dorsal decubitus, and by constipation. 



964 DISEASES OF THE NERVOUS SYSTEM 

Diagnosis. — Focal symptoms, as hemiplegia, indicate organic dis- 
ease. The mere existence of such symptoms, as flushing, heat, or 
pressure in the head, cannot be used for diagnosis, because they are 
often due to neurasthenia, or to hypochondriasis. Marie and Leube 
have never made the diagnosis of brain hyperemia. The great simil- 
arity between the symptoms of anaemia and hyperaemia of the brain 
has been noted. 

Treatment. — Active congestion is treated by slight elevation of the 
head; by venesection in extreme or very plethoric cases in adults, or 
in children by application of leeches over the mastoid bone, the veins 
of which connect with those of the brain ; by free purgation, by 2 drops 
of croton oil, followed by mercurials and concentrated salines, to draw 
the blood to the large abdominal vessels; by hot baths, to draw the 
blood to the periphery. Some practitioners prefer to give cool baths, 
with active friction; by vasoconstricting measures, especially digitalis; 
alcohol and opiates (save in small doses) should be avoided, and bro- 
mides should be used; ice may be applied to the head and carotids; 
a light — especially a fluid diet should be given. 

III. (Edema of the Brain. 

Etiology. — (Edema of the brain results from the same general 
causes as general oedema : (a) circulatory disturbances, as venous con- 
gestion in cardiac disease, emphysema, and the acute infections; and 
(6) the marantic group, including cachexia and nephritis. Collateral 
and inflammatory oedema may develop around brain tumor, abscess, 
or hemorrhage. In some instances brain oedema occurs in the death 
agony. It may also develop when the brain shrinks, hydrops ex vacuo. 

Pathology. — The brain is pale, moist, and glistening on section, 
the so-called "wet brain/' The affection may be general or local; 
the ventricular and subarachnoid fluid is usually increased. The 
volume of the brain may be somewhat increased in the generalized 
form. 

Symptoms. — The symptomatology is indefinite, and a certain diag- 
nosis cannot be made between oedema and lessening of the capillary 
velocity (adiamorrhysis). When the oedema is localized, transient 
focal symptoms may develop, as unilateral convulsions, hemiplegia, 
or even crossed paralysis; the latter was observed personally in cases 
of nephritis. Great variability in the symptomatology of organic brain 
disease may be due to associated oedema. Traube held that brain 
oedema causes the uraemic manifestations of nephritis, a view vigor- 
ously opposed by Cohnheim. 



CEREBRAL HEMORRHAGE 965 



IV. Cerebral Hemorrhage. 

This is the most common and important of all brain lesions, and its 
symptoms involve an enormous part of brain pathology. It is usually 
hemorrhage into the brain substance, and is spontaneous, i.e., it does 
not result from trauma. Although apoplexy strictly refers to a "stroke," 
which is symptomatic of various other lesions, it is used to indicate 
hemorrhage into the brain (Rochoux). 

Etiology. — (a) Miliary aneurysms are the chief, and according to 
some, the sole cause of hemorrhage of the brain; the leading issue at 
present relates to their pathogenesis. According to many authors, the 
causes of hemorrhage are (6) those of arteriosclerosis (alcoholism, 
plumbism, syphilis, hard physical work, contracted kidney, gout, 
diabetes, and over-eating), but others maintain that atheroma does 
not per se predispose to hemorrhage. Eighty per cent, of hemorrhages 
occur after the fortieth year of life. It may occur in early life from 
glioma, whooping-cough, or trauma. More cases occur in men (80 per 
cent.) than in women. Heredity is not an uncommon factor, but relates 
rather to renal and arterial lesions than to an actual heredity of hemor- 
rhage; this is especially emphasized by English writers, and by Dieu- 
lafoy. Hemorrhage is most common among civilized races and in 
temperate zones, because of the strenuous habits of life. For years 
the importance of the apoplectic habitus (plethora, ruddy face, short, 
thick neck, wide shoulders and chest, round, small body and large 
muscles) has been emphasized, although Gowers finds most of his cases 
in thin individuals. Contracted kidneys are found in 33 per cent, of 
cases of cerebral hemorrhage, and are among the chief causes of athe- 
roma and miliary aneurysm, (c) Increased arterial tension is usually 
considered an important etiological factor. Hypertension alone is less 
important than its relation to arteriosclerosis and miliary aneurysms, 
which occur where the blood pressure is greatest, as where the vessels 
branch. Rupture is also seen in hypertrophy from stenosis at the 
isthmus of the aorta. Syphilis is usually considered a factor, but it more 
frequently produces softening than hemorrhage; it is a causal factor of 
aneurysms of the large vessels of the brain. Violent exertion, excess 
in liquor, excitement, coitus, straining, overeating, vomiting, coughing, 
or convulsions, may cause rupture of an already-diseased vessel, or a 
miliary aneurysm. A healthy vessel almost never bursts, however 
high the blood pressure. Embolism from heart disease may produce the 
" embolic aneurysm/' Sometimes trauma is a factor, usually, however, 
with the causes mentioned, (d) Permeability of the blood vessels causes 
a few cases. In nephritis, purpura, various anaemias, leukaemia, septic 
infection and specific fevers, hemorrhage by diapedesis through the 
arterial wall is sometimes seen, and embolism is occasionally causative. 
Pathology. — Hemorrhages most often occur in the branches of the 
arteria fossae Sylvii. Among its branches the lenticulostriate artery 
of Duret, called, by Charcot, the artery of hemorrhage, is the seat of 



966 DISEASES OF THE NERVOUS SYSTEM 

hemorrhage in 60 to 75 per cent, of cases. Though the vessel is small, 
it is likely to rupture because (a) it is so near to the large internal carotid 
and its course is very direct; (b) the blood pressure is high; (c) the 
vessels have no special external support; (d) there is no collateral cir- 
culation, hence no relief to pressure, rendering the vessels tortuous. 
Rupture occurs very often in the long direction of the nerve fibers of 
the internal capsule. The veins stagnate very easily in this locality. 
Hemorrhage is almost always arterial. Miliary aneurysms were de- 
scribed by Brunner in 1700, but Charcot and Bouchard (1866) empha- 
sized their frequent relation to brain hemorrhage. They are fusiform, 
more rarely sacciform, enlargements of the arterioles, sometimes mul- 
tiple, like a bunch of grapes, measuring T 6o to -h of an inch; they 
may be seen with the naked eye, but are best observed by careful wash- 
ing or macerating in water, and examination on a slide under a low 
power. They are found mostly in persons over forty years of age, and 
iii the locations where hemorrhages are most common, i.e., in the 
central ganglia. Their pathogenesis is obscure. Charcot and Bouch- 
ard described a change in the outer tunic (periarteritis) but Eichler 
and Zeigler held that intimal changes were primary. Roth finds that 
miliary aneurysm is due to atrophy of the muscular coat ; this is at 
present the generally accepted theory. They are the chief, and perhaps 
the sole, cause of spontaneous hemorrhage, although rare cases result 
from simple arterial degeneration. Large aneurysms will be considered 
separately. 

Localization. — Hemorrhage is most common about the lateral ventri- 
cle, i.e., in the caudate and lenticular nuclei, the internal capsule and 
the adjacent centrum ovale, extending to the optic thalamus, but rarely 
beginning in it. Hemorrhage in the white matter has usually an elon- 
gated form. It is much less common in the cortex, pons, crus, cerebellum 
or medulla. Though it occurs mostly in the substance of the brain, 
hemorrhage may either rupture on the surface, or break into the ven- 
tricles, causing sudden death; this is the usual autopsy finding in recent 
apoplexy. Hemorrhage is usually single. The multiple form, is ob- 
served in anaemia. When the skull is removed in cases of large hemor- 
rhages, the dura is tense, the convolutions are flattened and pale, the 
falx is pushed toward the other side, and the fissures are not distinct. 
Fluctuation may be felt in rare cases, and on section the focus is seen; 
it sometimes involves the entire hemisphere, or may be no larger than a 
pea, but usually the size of a hazel-nut or walnut. The brain around 
the focus is softened from pressure, cedematous, and, in the focus, 
torn and pulpy. The dark clot later becomes chocolate-colored, 
then yellow-red, and finally yellow-white. The wall of the focus is 
irregular in the gray nuclei, and regular in the white matter and threads 
of bloodvessels run through it. Microscopically, leukocytes laden with 
fat drops, hsematoidin and disorganized tissue are found. As the blood 
absorbs, the cavity becomes more regular and encapsulated by inflam- 
mation, and contains a serous or milky fluid; this is the apoplectic 
cyst of Virchow. Final replacement of the focus by an apoplectic scar 



CEREBRAL HEMORRHAGE 



967 



is much less common. Traumatic hemorrhage may occur, though 
infrequently, near the point of injury or contre coup on the opposite 
side; it sometimes takes place after a week or more; this is the late 
traumatic hemorrhage of Bollinger, which occurs near the fourth ven- 
tricle and aqueduct of Sylvius, and probably, in areas of traumatic 



Fig. 56. 



INTERNAL 
CAPSULE— "7^tic_ 

j^alKmus 




Showing course of individual fibers of motor tracts. 

softening. Brain hemorrhage may indirectly press on other parts, 
may press on their arteries and veins, or directly sever the nerve fibers 
of the internal capsule. 

Secondary degeneration occurs in the pyramidal tracts, mostly as a 
result of lesions of the internal capsule. It is usually partial, and 
sound and diseased fibers intermingle; it descends through the crus, 
pons, medulla, and cord, in the latter of which it involves the inner 
part of the anterior columns of the same side (the uncrossed or direct 
anterior pyramidal tract), and part of the lateral columns of the opposite 
side (the crossed lateral tract). These areas become progressively 
smaller, and cease just above the conus medullaris. In children a 
cerebral lesion may cause degeneration in the anterior horns of the 
cord and their fibers. An ascending degeneration occurs only when 
the large pyramidal tracts of the cortex are diseased, except in the 
young, in whom degeneration of all neurones is prone to follow the 
destruction of one neurone. (See figures under Localization in 
the Spinal Cord.) Other degenerations may occur, (a) The optic 
radiation degenerates when a lesion occurs in the cortex of the 
cuneus, and also degenerative changes in the external geniculate body 
and pulvinar. After years it may reach the optic nerve, (b) Hemor- 
rhage in the second and third frontal lobes leads to degeneration in the 



968 



DISEASES OF THE NERVOUS SYSTEM 



anterior limb of the capsule, median basal fibers of the cms, and the fibers 
connecting the optic thalamus with the cortex, (c) Lesions in the tem- 
poral lobes cause degeneration in the lateral part of the crus. (d) De- 
generation in the median lemniscus follows diseases of the cortex, the 
subthalamic region and the upper part of the pons; it crosses to the 



Fig. 57. 




Horizontal section through the right hemisphere; 1, Cortex; 2, white substance; 3, internal capsule: 
4, optic thalamus; 5, lenticular nucleus; 6a, anterior horn; and 6b, posterior horn of the lateral 
ventricle. (After Dejerine.) 

opposite nuclei of the medulla, and after years destroys the ganglion 
cells in the posterior columns of the cord. Cerebellar hemorrhage 
may (rarely) cause degeneration of the arm of the pons and of the 
corpus restiforme. 

Symptoms. — Prodromes are most rare. Miliary aneurysms pro- 
duce no symptoms until they rupture, and premonitory symptoms are 
due to atheroma. None of them are pathognomonic. They may be 



CEREBRAL HEMORRHAGE 969 

(a) general, as described under congestion and softening (v.i.); 

(b) cardiorenal, as hypertrophied heart, high arterial tension, and 
the urinary findings of contracted kidney; or (c) sometimes focal, as 
diplopia, alexia, facial paresis, dysarthria or preparalytic chorea. 
Possibly in some cases prodromal symptoms are due to an initial small 
hemorrhage, or to hemorrhage developing very slowly. 

The Insult or Stroke and Its Primary Symptoms. — The " stroke," 
or apoplexy is usually sudden; its most common general symptom is 
coma, which may be absent in small lesions, and its most common focal 
symptom is hemiplegia. It may develop during effort or excitement, 
or again without cause, as during sleep, when the head is low. In 
ingravescent apoplexy the onset may be gradual, with delirium, con- 
vulsions, and finally coma; it is due to hemorrhage external to the 
lenticular nucleus, and later involves the internal capsule (hemiplegia). 
Death may, in rare instances, occur in five minutes (Abercrombie) 
from rupture into the ventricles, or from direct pressure on the medulla 
(fulminating apoplexy). 

The insult, or stroke, is due chiefly to ancemia of the cortex, and to 
some extent, to direct brain trauma, pressure by the hemorrhage on 
other vessels, serous infiltration and alterations in the cerebrospinal 
fluid (in which lumbar puncture sometimes shows blood). Its cardinal 
typical symptoms are coma, which is greater the nearer the lesion is 
to the optic thalamus and third ventricle; flushed face, or some- 
times pallor or cyanosis; usually a full, tense, regular and slow pidse; 
long, deep, stertorous breathing (due in part to palate paralysis); the 
cheeks puff out, but are drawn in on inspiration, as a result of paralysis 
of the buccinator muscle; inspiration is less irregular than it is usually 
said to be; yawning is frequent (Todd) ; the temperature usually suffers 
an initial fall, but rises when reaction sets in, though lesions in the 
pons, medulla or central ganglia may cause an initial rise. The pupils 
are variable, usually wide, from paralysis of the third nuclei, or from 
sympathetic stimulation; they are sometimes unequal, and in deep 
coma, reactionless. They may be narrow from irritation of the oculo- 
motor nucleus in lesions of the pons, or when the ventricles are involved. 
Convulsions are infrequent. The head and eyes look toward the side 
of the brain lesion ("conjugate deviation"), a flaccid hemiplegia 
occurs, in which the limbs fall limp when they are lifted; the paralyzed 
muscles appear semi-fluid and lax (Heilbroner) ; the reflexes are gone, 
which symptoms will be described in detail below. There are invol- 
untary evacuations of urine and fseces. Ollivier described an increase 
of the urine with a low specific gravity (1,004), and transitory albu- 
minuria and glycosuria; these are usually due to a large lesion pro- 
ducing indirect or distant pressure on the medulla, or to lesion in the 
medulla itself. 

The permanent damage can only be estimated when the reaction is 
passed. The direct focal symptoms are those of the hemorrhage itself, 
and the subsequent cyst or scar; they are permanent if essential structures 
are involved, as the internal capsule. Indirect focal symptoms are those 



970 DISEASES OF THE NERVOUS SYSTEM 

of other structures disturbed by pressure, cedema or inflammatory 
reaction. Time is required to separate these two classes of symptoms. 
The pulse and respiratory symptoms, conjugate deviation, albumin- 
uria and temperature are usually indirect symptoms. 
Details of improtant symptoms : 

1. Convulsions are not common; they indicate involvement of the 
pons, ventricles, cortex or corpus striatum. 

2. Conjugate deviation, described by Vulpian, but especially by 
Prevost, is a transitory phenomenon in which the lateral muscles of 
the head and eyes are paralyzed; their fellows on the sound side con- 
tract, so that "the patient looks at his lesion" (Prevost); that is, in 
left hemiplegia, the eyes and head look toward the right side of the 
brain, where the lesion is located. The centres paralyzed are in the 
lower parietal lobe (gyrus angularis and gyrus supramarginalis, Lan- 
douzy). It disappears in a few days, because the sound side of the 
brain compensates or because it is a distant pressure symptom, or 
at the most, only a moderate paresis remains, shown by nystagmus. 
Conjugate deviation may also be due to irritation or convulsions 
(Jacksonian epilepsy), when the patient "looks away from his lesion" 
(Landouzy), i.e., toward the side affected with convulsions. These 
differ from the deviation in localization in the pons (q.v.). 

3. The hemiplegia (see Localization, Internal Capsule) is due 
to lesion of the internal capsule (66 to 75 per cent, of cases). During 
deep coma it is often difficult to determine which side is paralyzed. 
The affected side is usually flaccid, and the mouth shows greater 
puffing on the hemiplegic half. If the coma is not profound, the 
sound arm and leg may move. Sometimes, especially with hemor- 
rhage into the lateral ventricle, the paralyzed side is rigid (early rigidity 
or contracture). The temperature is at first lower on the hemiplegic 
side from paralysis of a cortical centre. Later, during reaction, it is 
higher on the side of paralysis and may occur with oedema in this 
arm and leg. After consciousness returns, the contralateral hemi- 
plegia is more clearly seen. The lower two-thirds of the face (nose, 
mouth, cheek) are paralyzed, but the upper third (eye and forehead) is 
usually quite free; in very rare cases only, a total facial paralysis is seen. 
The lids can be moved, but the nasolabial fold is obliterated, the lips 
cannot be puckered as though to whistle, the mouth is oblique, or a 
little triangular when the teeth are shown. The upper part is so 
often unaffected because it is innervated from both hemispheres, or 
because it has two distinct centres and paths, whereas in peripheral 
facial paralysis all branches are involved, and atrophy and the reac- 
tion of degeneration occur. If the optic thalamus (q.v.) is intact, 
the paralysis is not apparent on emotional movements, as laughing. 
The tongue is slightly involved; when protruded it deviates toward 
the diseased side (Schiff, Heidenhain), because the sound genioglossus 
muscle pulls the tongue forward and over toward the hemiplegic 
side; the base of the tongue is higher on the paralyzed side; it may 
lead to some difficulty in the external speech mechanism (dysarthria), 



CEREBRAL HEMORRHAGE 971 

while internal speech (i.e., aphasia) is not often disturbed unless 
there is psychical alteration. The palate may hang lower on the 
paralyzed side, but this is of little importance because it varies physio- 
logically. Deglutition, mastication and phonation are but little or 
only transitorily involved; marked difficulty in mastication is usually 
associated with total hemianesthesia. In the trunk, paralysis of the 
trapezius and levator anguli scapulae causes sagging of the shoulder, 
while other muscles of the neck are relatively free. (Wernicke 
thinks certain cerebral fibers of the spinal accessory are involved, 
which is analogous to the partial facial paralysis.) The accessory 
muscles of respiration, as the scaleni, are involved on deep inspiration, 
and ordinary respiration is somewhat less complete, to which some 
would refer certain lung complications as atelectasis. Hughlings- 
Jackson finds respiratory movement greater on the paralyzed side 
in automatic breathing and greater on the sound side in forced breath- 
ing. Early, the paralysis of the arm and leg is often absolute, some- 
times partial (hemiparesis). The arm is usually more involved than 
the leg. In rare cases the arm may be free in linear lesions; again 
the leg may be unaffected, or the face remains free (see Internal 
Capsule Localization) ; monoplegia is much less common than in 
cortical and subcortical disease, and when one member is more affected 
than the others, there is still partial or "dissociated" hemiplegia. 
In the typical case the arm is most involved, though all parts on one 
side usually are somewhat paralyzed. The arm abductors, hand 
flexors, and finger extensors are most affected. In the leg, the extensors 
of the leg, dorsal foot flexors and knee flexors are most implicated. 
The paralysis is flaccid. Considerable improvement may follow (see 
Secondary Symptoms). The hemiplegia is almost invariably contra- 
lateral, i.e., opposite to the side of the lesion. (In the older literature 
hemiplegia on the same side, or collateral hemiplegia was described ; 
it was referred to the rare lack of decussation of the pyramidal tracts ; 
however, if the motor tracts do not cross in the brain, they usually 
cross in the cord. Collateral hemiplegia, of which Lederhose collected 
45 cases, is due (a) to more than one lesion, (6) to a focus pressing 
on the other side of the brain, or (c) to mistaking the early rigidity 
of the paralyzed side for the normal side, Pineles and Ortner.) 

4. Sensory disturbance has been considered in the topography of 
the internal capsule. It is observed mostly during the insult or reac- 
tion, is less important than hemiplegia, less frequent, less distinct, 
less complete and less stable. Some hemianesthesia is frequently 
found in early cases after careful examination, as disturbed tactile 
sensation, stereognostic sense and sometimes muscle sense, pains and 
hyperesthesia or paresthesia. A large lesion only, can cause a com- 
plete hemianesthesia, which very seldom occurs without some paresis. 
It affects the skin and mucosa of the nose, mouth, palate and eyes, 
but leaves the cornea intact (Grasset), which is supplied by the oph- 
thalmic ganglion (see Diagnosis). Cortical hemianesthesia is usually 
partial and most often united with a monoplegia; lesions a little 



972 DISEASES OF THE NERVOUS SYSTEM 

above the capsule, may produce hemianesthesia, involving the fibers 
from the thalamus to the cortex. Hemianesthesia also occurs in 
lesions of the crus, pons, medulla and spine (q.v.). 

5. The special senses are not often involved, or are affected but 
temporarily. Hemianopsia is frequent (Gowers and Kines), usually 
occurs with conjugate deviation, is temporary, and is often over- 
looked; it probably is due to indirect pressure on the optic thalamus. 

6. The reflexes of the skin, cornea, pupils, mucosa? and tendons are 
suspended when there is complete coma. Theoretically they should 
be increased by withdrawal of cerebral inhibition, but the central 
nervous system is almost wholly paretic during severe coma. After 
the stroke they return slowly, first on the sound side; the corneal 
reflex, the reaction of the pupils to light, the epigastric and other skin, 
and tendon reflexes return in the order named; the patellar reflex is 
often exaggerated. On the hemiplegic side, they return slowly, the 
periosteal tendon reflexes and patellars often become exaggerated; 
this is due to interrupted inhibition. The patellar reflex on the dis- 
eased side may return only after a considerable time. The skin reflexes 
return slowly, especially the epigastric, cremasteric, scrotal and 
mamillary (Jastrowitz) ; this is a point of early diagnostic value; 
they probably have a higher centre than have the tendon reflexes, 
although the explanation of their conduct is not clear; it has also been 
suggested that there is a cerebral centre controlling Setchenow's 
inhibitory reflex centre in the medulla; when this higher centre is 
affected, the medulla centre wholly inhibits the reflexes. 

The Babinski sign (toe phenomenon) indicates organic pyramidal 
disease and may be found very early; when a sharp object is slowly 
drawn over the outer part of the sound sole, there is plantar flexion 
of the large, and sometimes of the other toes; when drawn over the 
diseased sole there is great dorsal flexion (extension) of the great toe. 
After the prodromes and the initial primary insult, coma and reaction 
are over, the chronic symptoms can be studied to the best advantage. 

The Chronic or Secondary Symptoms. — The indirect focal symp- 
toms (conjugate deviation, coma, etc.), the inflammatory reaction and 
collateral oedema disappear; this is followed usually by considerable 
improvement. 

1. If the hemiplegia is indirect, from lesion without the capsule, 
marked improvement or rarely, total recovery ensues. Complete 
lasting hemiplegia follows total division of the pyramidal tracts, due 
to hemorrhage from the anterior choroid artery (Kolisko). The face 
may recover rapidly; certain muscles are entirely unaffected or are 
involved for a short time only; this is explained by Broadbent's theory 
that muscles used in pairs are little involved or escape entirely; with 
some modification of his theory, we find that: the intercostals , mas- 
seters and trunk muscles used together, innervated from both hemi- 
spheres and having little differentiation in function, escape permanent 
paralysis. The muscles of the arm and hand have especially compli- 
cated functions, are more often used alone, are innervated almost 



CEREBRAL HEMORRHAGE 973 

wholly from one hemisphere, and therefore suffer the greatest per- 
manent damage. In adults the hand is usually disabled for life. 
The legs are much used together, have some innervation from both 
hemispheres, and often show some improvement after paralysis. Just 
how compensation occurs is undetermined. Broadbent thinks that 
the bilateral spinal and bulbar nuclei enable " paired muscles" to 
be innervated from the sound hemisphere. Possibly uncrossed fibers 
in the anterior (and lateral) columns may explain the phenomenon. 
Compensation is not an absolute advantage, for Brown-Sequard found 
the sound side reduced in strength in 50 per cent, of his cases. The 
face often improves after an attack. In the arm the residual paralysis 
affects functionally associated muscle groups rather than individual 
muscles, as the muscles supinating the forearm, those abducting and 
lifting the arm and shoulder, those moving the elbow, opening the 
hand, and apposing the thumb (Wernicke and Mann). The shoulder 
improves a little, the elbows considerably, the hands very little. In 
the leg, the flexors, dorsal flexors of the foot which " shorten" the 
leg in walking, abductors and internal rotators of the hip are most 
involved. The hemiplegic gait is awkward, the foot is swung out 
and around in a half circle and scrapes the ground. The power of 
the paralyzed leg is greater when it is used with the sound leg, as in 
walking, than when it is used by itself. 

2. The contracture, the important posthemiplegic manifestation, is 
the transitory or permanent fixation of a joint in an abnormal posture 
from nutritive or functional factors. Passive contractures are mechan- 
ical, as from muscular shortening, while active contractures result 
from disease of the central nervous system. Early contractures are 
often regarded as tonic spasm (myotatic irritability). The late con- 
tracture develops in two to four weeks and is quite typical ; the shoulder 
is lifted, the arm adducted to the chest, the elbow rigid, the forearm 
pronated, the wrist flexed, and the fingers flexed even violently into 
the palm. When the wrist is passively flexed the fingers can some- 
times be extended. In general the contracture involves both extensors 
and flexors, but more often the latter. The contractures occur in the 
muscles which are least paralyzed. In the lower extremity, the con- 
tracture is not marked (in the thigh there is often only a trace), the knee 
is extended, plantar flexion of the foot occurs (pes equino-varus) , the 
great toe is dorsally flexed. Locomotion is difficult, for there is 
bending of the trunk to the" sound side, lifting of the pelvis because 
of the adduction paralysis, and swinging of the foot over the sound 
foot. There may be pain in walking, and the sound leg also suffers 
some slight contracture. Contracture may occur in the face, platysma 
and sternomastoid, but the trunk is rarely affected. Contractures are 
increased by cold, irritation, and movement, and decreased by massage, 
warmth and sleep. They may be caused by irritation in the periph- 
eral nerves, inflammation in joints or muscles, interruption of inhibition 
in the pyramidal tract or irritation acting on lower centres as the pons 
or medulla. Hitzig regards them as involuntary associated movements. 



974 DISEASES OF THE NERVOUS SYSTEM 

In rare cases the paralyzed side remains lax (hemiplegie flasque of 
Bouchard, occurring largely in children). 

3. Associated movements are variously explained; by Westphal as 
due to lessening of reflex inhibition, by Hitzig as movements attempted 
in paralyzed muscles but reflected to their associates, and by Leube 
as due to bilateral representation in the hemispheres; examples: an 
effort to grasp with the sound hand produces a similar movement in 
the one paralyzed; yawning or coughing produces a movement of 
the paralyzed arm ; movement of the diseased side occurs after passive 
movement of the sound one; movement of the paralyzed foot results 
when the patient attempts to flex the hip. 

4. Hemitremor is uncommon. The muscles are stimulated from 
the brain but not enough vibrations occur for actual involuntary 
movement. 

5. Atrophy is less marked than in peripheral and spinal lesions, but 
may occur in both spastic and flaccid cerebral forms, though more 
in the latter; Stein ert recently concluded that atrophy is as frequent 
in cerebral as in peripheral paralysis. Charcot referred it to degen- 
eration of the anterior horns of the cord, while Quincke and Senator 
assume that it results from injury to some trophic paths. It is dis- 
tinct from lack of development in the young. It develops in a 
month or two, has no relation to the degree of paralysis, is often asso- 
ciated with disturbed sensation and muscle sense, affects principally 
the arm, occurs in large lesions which are either (a) cortical in the 
region of the third branch of the artery of Sylvius, or (b) central in 
the distribution of lenticulothalamic artery. The electrical irritability 
of the muscles is either normal or somewhat depressed. The skin also 
may atrophy. 

6. Posthemiplegic chorea (Wier Mitchell, Charcot, Raymond) results 
in 80 per cent, of cases from lesions in the internal capsule, or near 
it, in the optic thalamus, the lenticular or caudate nuclei, from which 
irritation is reflected to the brain cortex. It sometimes is preparalytic 
(Grasset). It develops months or years after small lesions, when the 
hemiplegia and rigidity are largely gone. It occurs especially in the 
arm, causes movements similar to but coarser than those of chorea, 
sometimes resembles the tremor of multiple sclerosis or paralysis 
agitans, and is often associated with pain and sensory disturbance 
(see Localization, Internal Capsule). In posthemiplegic athetosis 
(Hammond), the fingers and toes are incessantly moved, athetosis 
meaning "without fixed position/' It is a "mobile spasm" consist- 
ing of somewhat spasmodic, slow, coordinated movements in paralyzed 
members; it is frequent in partial paralysis acquired early in life, 
is slow in development, appears after the paralysis has regressed, and 
has the same localization as hemichorea. The following differentiation 
by Greidenberg and v. Monakow gives the main characteristics of 
the two affections : 



CEREBRAL HEMORRHAGE 975 



Hemichorea. vs. Hemiathetosis. 

1. Face, trunk, whole extremity in- 1. Chiefly or alone in forearm and hand 

volved; may pass to all extrem- (fingers) and in leg and foot (toes); 

ities. simultaneous innervation of an- 

tagonists; other parts paretic and 
stiff. 

2. Excursion active, manifold, tremor- 2. Slow rhythmic hyperextension, elas- 

like, purposeless, increased by ex- tic resistance, seems purposive, 

ertion, tension lost by irritation. joints fixed. 

3. Contracture little or none; limbs re- 3. Contracture frequent, but spasmus 

laxed; no great deformity. mobilis often great. 

4. Hemiansesthesia frequent. 4. Hemiansesthesia rare (almost never 

in children). 

5. Quiet in sleep. 5. Not always quiet in sleep. 

6. Increased by movements and at- 6. Lessened to some extent by move- 

tempts to suppress them. ment. 

7. In trophic and vasomotor disturbance (v. s., Muscular Ateophy), 
the paralyzed members are usually cool, moist and sometimes cedema- 
tous. The skin is glossy , even livid and fissured. Nothnagel observed 
iu some cases paralysis of the cervical sympathetic system causing 
increased temperature, redness, narrowing of the eye fissure, drooping 
of the upper lid, retraction of the eyeball, lachrymation and narrow 
pupils. Sometimes there is overgrowth of the hair. Bed-sores were 
considered trophic by Charcot, but can usually be avoided by care 
regarding pressure or heat, and by cleanliness. Swelling of the joints 
and hypertrophic neuritis (Charcot) on the hemiplegic side are rare. 

8. Psychic disturbance is not symptomatic of brain hemorrhage, and 
is chiefly referable to arteriosclerosis. It is evidenced by self -concen- 
tration, weak memory, insomnia and irritability. Carpani found 
more mental alteration when the left half of the brain was diseased. 
Laughing and weeping are referable to disease of the optic thalamus 
(q.v.), or to disease of the median fibers of the pons (Brissaud). 

Diagnosis of Brain Hemorrhage.— Two cardinal features, coma and 
hemiplegia, together with the typical insult facilitate diagnosis. In 
cases with slow onset, differentiation from thrombosis (q. v.) is difficult. 

Coma. — In syncope the pulse is fast, weak and often irregular; in 
"cardiac apoplexy," an insult follows heart rupture, myocarditis, and 
various forms of heart failure, and differentiation from rapidly fatal 
brain hemorrhage may be impossible. It is always dangerous to make 
a diagnosis of alcoholic coma; an intoxicated individual may suffer 
injury, basal fracture or actual apoplexy; an opinion should be with- 
held until such complications can be excluded, even though the 
alcoholic coma is usually incomplete, the vomitus and breath 
smell of alcohol, violent struggling is frequent, and early con- 
vulsions and focal symptoms are rare. Opium coma is charac- 
terized at first by slow onset, slow respiration, slow, hard pulse, 



976 DISEASES OF THE NERVOUS SYSTEM 

flushed skin, great contraction of the pupils, opium in the urine or 
stomach washings, and absence of convulsions and focal symptoms; 
later there are Cheyne-Stokes respiration, rapid pulse, clammy 
cyanotic skin and dilated pupils. Hemorrhage in the pons produces 
narrow pupils, which are often unequal. In this and similar intoxi- 
cations, the focal symptoms, and reflexes of apoplexy are lacking. 
While in general the diagnosis of apoplexy during the coma is pre- 
carious, urcemic coma rarely occurs without premonitory symptoms, 
as headache, drowsiness, delirium, restlessness, vomiting, myosis, 
retinitis, or less often convulsions; the coma is often less profound 
than in cerebral hemorrhage. The renal, cardiac and arterial findings 
of nephritis may also occur in apoplexy, of which nephritis is a fre- 
quent cause (33 per cent.), and it must be remembered that focal 
symptoms in uraemia sometimes occur; the author has repeatedly 
observed hemiplegia and even crossed paralyses. In deep coma 
rigidity may be observed in both uraemia and apoplexy, but in uraemia 
it is often variable. In diabetic coma, the fruity, acetone breath, 
acetone in the urine, headache, unrest, KussmauFs breathing and 
absence of focal symptoms are characteristic. The coma may be 
sudden, granular casts are frequent and the sugar may disappear; 
the diagnosis is then only suggested by a clear history of glycosuria. 
Symptomatic apoplexy is of more theoretical than practical importance; 
transient coma and hemiplegia sometimes occur in brain oedema, 
congestion, progressive paralysis, multiple sclerosis, and more rarely 
in epilepsy and tabes. Hemiplegia, not resulting from any lesion 
may occur when the condition of the blood is altered (alcoholism, 
plumbism, gout, tuberculosis, cancer, uraemia, diabetes, pneumonia). 

Hemiplegia. — This is a prominent finding in embolism and throm- 
bosis (q.v., for Differentiation); an exact diagnosis is often impos- 
sible. Kolisko states that most cases with the clinical diagnosis of 
embolism prove to be hemorrhage, and vice versa. Hemiplegia may 
occur in brain abscess, and meningitis. When it occurs in meningitis 
with coma, there is headache, more generalized convulsions, rigidity, 
hyperaesthesia, optic neuritis, eye-paralyses and fever. In extradural 
haematoma and pachymeningitis, the Jacksonian epilepsy followed by 
cortical paralysis is distinctive, i.e., the focal symptoms are prominent 
compared with the general symptoms of early apoplexy. Hemiplegia 
also occurs in hysteria (q.v.), syphilis, brain tumor, trauma, and in 
some cases of chorea and paralysis agitans. 

Other Locations of Hemorrhage. — (a) Hemorrhage may occur in 
the meninges (see Diseases of Meninges), (b) It may occur, though 
rarely, in the cortex; Jacksonian epilepsy in subcortical lesions, con- 
vulsions and rigidity may be severe and lasting (Mills), (c) Ven- 
tricular hemorrhage is usually secondary to hemorrhage in the corpus 
striatum or optic thalamus and usually reaches all the ventricles. It 
may in rare cases be primary from aneurysms or ruptured veins 
in the choroid plexus (Dana). One-third of all cases are in persons 
under forty years of age. It occurs usually with violent symptoms, 



CEREBRAL HEMORRHAGE 977 

convulsions (33 per cent.), early and sometimes bilateral rigidity. 
The conjugate deviation changes and turns to the other side, the 
pulse is slowed, the temperature falls, the reflexes are suspended, 
Cheyne-Stokes breathing, glycosuria and polyuria (Pascheles) develop, 
and death usually results within a day; the onset, however, is some- 
times slow (Broadbent). (d) Hemorrhage in the crus (q. v., Localiza- 
tion) may be primary but is usually descending, from bleeding near 
the internal capsule. Crossed hemiplegia oculomotoria (Weber's 
type), crossed ptosis (Richards) or diplegia (Paquet) may be observed. 
(e) Apoplexy in the pons (q.v.) occurs in 10 per cent, of cases, often 
in the median line, and frequently with convulsions. Paralysis and 
convulsions may occur in the arms or legs only; the trunk musculature 
is involved more frequently than in higher hemorrhages. The eyes 
look away from the side of the lesion. The pupils may be large from 
paralysis or small from stimulation of the third nerve; in the latter 
instance opium poisoning must be differentiated. Respiration is 
affected early, vomiting is frequent, there is often early high fever 
and death is usual within twenty-four hours. It has occurred in seven 
minutes. (/) Hemorrhage in the medulla will be considered later. 
Early or instantaneous death is frequent, but a gradual onset is known. 
It is rarely diagnosticated. It may very rarely induce gastro-intestinal 
hemorrhage, (g) Cerebellar apoplexy occurs in 5 to 8 per cent, of 
cases. Vomiting is very frequent (50 per cent.). The insult is some- 
times less marked than in the usual type, and "the absence of hemi- 
plegia is more significant than its presence/' (Gowers). Hemiplegia 
and symptoms from the fourth ventricle are due to indirect pressure 
or secondary ventricular hemorrhage. Cerebellar symptoms, as ataxia, 
may result (see Localization). 

Prognosis. — The prognosis concerns (a) the immediate danger and 
(6) the ultimate outcome, (a) The immediate prognosis is always 
serious. In hospital cases 75 per cent, die but in general practice 
66 per cent, survive the first stroke, and 33 per cent, the second, and 
very few the third. When death occurs, it is usual in one-half to two 
days, but the outcome is uncertain for a week, because light cases, 
even the rare forms without coma, may rupture into the ventricle 
with rapidly fatal result. Coma lasting more than twenty-four to 
thirty hours is dangerous. Early low fall of temperature or its rapid 
early rise is unfavorable, indicating a large focus. For the same 
reason, much conjugate deviation, relaxed sphincters, impaired breath- 
ing, trachial rattling, bilateral or ventricular symptoms, marked glyco- 
suria or albuminuria, decubitus in the first week, convulsions and 
rapid pulse are unfavorable. The mode of death is as follows: the 
breathing becomes more rapid, irregular, of the ominous Cheyne- 
Stokes type, and rattling from accumulated secretion in the air- 
passages; the slow and regular pulse becomes rapid, small, irregular, 
often with a rise of temperature, and finally ceases, but respiration 
for a time continues; death occurs in total coma. 

G2 



DISEASES : THE XEBYOUS SYSTEM 

Ultimate outcome — the symptoms of shock disappear and the 
patient becomes partly conscious or delirious: the period of reaction 
begins, usually within forty-eight hours after the onset. The pulse 
becomes faster, the temperature rises, pain develops in the head and 
limbs and sometimes, though rarely, the paralyzed limbs become rigid. 
Life still hangs in the balance, and the patient may die from the reac- 
tion, from hypostatic pneumonia, called trophic by some writers, 
from pulmonary oedema or hemorrhage, acute decubitus, or from a 
second brain hemorrhage. Reaction is over in one to six weeks. 
If the patient survives the insult and reaction, there is always some 
improvement, depending on the extent and localization of the injury, 
which can be determined only after weeks or months. If movement 
appears in three or four week-, the outlook is good: if it does not 
return in three or four months, it is not likely to develop later. Dis- 
appearance of indirect pressure leads to bettering i of damage to 
the sensory nerves and those of special sense, n ) of motility, fir-- : : 
the trunk and face, then of the leg, and less of the arm. Absolute 
recovery is possible but improbable. Hemichorea and heniiathe: ~> 
are incurable. Broken neurones never unite, and secondary degenera- 
tion, contractures and increased reflexes result. Exaggerated reflexes 
developing a few weeks after the injury, are forerunners of contrac- 
tures and ankle clonus, which preclude full regression. The outlook 
is fairly sood in children when the hemorrhage is not due to blood 
•disease, because compensation is likely to occur. Recurrence is pos- 
sible in decrepid and aged su : : : t::- although less common than 
usually believed; the average Luration of life is five years Dana). 

Treatment. — 1. Prophylaxis. — Prophylaxis regarding worry, hard 
work, syphilis, the use :: alcohol, eating and excesses is necessary 
when there is hereditary tendency toward hemorrhage, or when one 
hemorrhage has already occurred. 

2. The Insult. — Absolute quiet is indicated, and any movement, 
transportation or extended examination should be avoided, (b) The 
head should be slightly elevated, but flexion of the neck, tight clothes 
or anything hindering the return venous flow should be avoided. 
Bowles thinks that stertorous breathing is due to the position of the 
paralyzed palate, and that turning the patient on his side relieves it 
more effectively than does venesection. c Venesection is seldom 
used, since being discountenanced by Trousseau and Traube. It is 
certainly indicated only in robust individuals with strong hearts and 
tense vessels: about 12 ounces :: _ 1 should be withdrawn: the 
chief objection to venesection is the difficulty in diagnosis of cerebral 
hemorrhage. Any physician who has used it frequently will admit 
that he has occasionally bled patients with thrombosis, embolism, 
syphilis or tumor. In thrombosis and embohsm venesection incre 
the anaemia of the brain, which at present holds a prominent place in 
the pathology of hemorrhage. Gushing has shown that the high 
tension is a vicarious effort to keep the medulla supplied with blood. 
The same objection holds to compression of the common carotid. 



CEREBRAL EMBOLISM 979 

(d) Leeches and sinapisms are harmless but useless, (e) The ice-cap 
may be used, but cannot influence the deep circulation in the brain. 
(/) Evacuation of the bladder and bowels is indicated. Two drops 
of croton oil will act in an hour or two, and in case of failure, the dose 
may be repeated. Croton oil was Hughlings Jackson's only remedy. 
(g) The diet should be fluid and should be administered by the nasal 
catheter or by rectum, (h) The skin should receive attention: de- 
cubitus is prevented in practically all cases by care regarding posture 
and cleanliness. Heat and sinapisms must be used with greatest 
circumspection because the hemiplegic side is prone to necrosis and 
inflammation, (i) Symptomatic treatment of cardiac and of respira- 
tory failure is by champagne or ammonia, but this should not be 
given until necessary; treatment of restlessness or convulsions is by 
chloral in enema, or by morphine which theoretically congests the 
brain, but really quiets it without detriment. 

3. The Reaction. — During the inflammatory reaction the treatment 
is wholly expectant, and if possible should be conducted without 
drugs. 

4. The Chronic Stage. — (a) Gentle massage of the muscles, move- 
ment of the joints and alcoholic rubs are instituted as soon as the 
coma subsides, (b) Potassium iodide is indicated when the reaction 
subsides, (c) As soon as the leg improves, that is, in four to eight 
weeks, the patient should be encouraged to sit up and walk, (d) 
Application of the faradic current to the limbs is certainly valuable 
after two to four weeks, and, supplemented with massage of the 
paralyzed groups and their antagonists, minimizes the contractures. 

(e) Hydrotherapy is valuable; cool baths or rubs are efficacious 
except in anaemic or poorly nourished individuals. Warm baths are 
to be avoided in old people and strychnia in all cases. 



V. Cerebral Embolism. 

Embolism and thrombosis of a brain artery result in brain softening 
(encephalomalacia), which is next after hemorrhage in importance 
and frequency, and is one of the best known subjects in brain pathology. 
Brain softening from arterial occlusion is not the "softening of the 
brain " known to the laity, who give that name to progressive paralysis 
of the insane. Encephalomalacia must not be confused with inflam- 
matory softening {encephalitis). Softening was first recognized bv 
Abercrombie in 1818, and by Rostan in 1820, while those coming 
after them usually considered it inflammatory. Virchow's researches 
on embolism confirmed the views of Rostan and Abercrombie, while 
Cohnheim elaborated the vascular relations, and Panum, Piltz, Pre- 
vost, Cotard and Cohn worked out Virchow's views. 

Etiology. — In embolism, Spierling found the kidneys involved in 
77 per cent., the spleen in 54 per cent., and the brain in 22 per cent, 
of cases, (a) About 90 per cent, is due to heart disease. Most com- 



980 DISEASES OF THE NERVOUS SYSTEM 

mon is acute endocarditis or acute exacerbations of chronic valvular 
lesions, in which the embolism is benign (mechanical) or malign 
(mechanical and septic). Calcarious fragments from the valves, or 
parts of torn valves, may be thrown into the brain. Of valvular dis- 
eases, mitral stenosis produces embolism most frequently because of 
stasis in the left auricle. Less frequent are cardiac clots formed in 
the weak hearts of decrepid, cachectic subjects, in myocarditis or in 
such acute diseases as typhoid. Weakened heart action and slow 
circulation are never the only cause, (b) Atheroma of the arch and 
aneurysm are far less frequent causes, as are (c) lung lesions, as tuber- 
culous cavities, abscess, gangrene or empyema (after irrigation), 
tumors, echinococcus, gumma or abscess of the heart, (d) In the 
rarest instances, lung tissue (Bottcher), fat embolism from fractures, 
pigment embolism (Frerichs) in malaria or liver cells in acute yellow 
atrophy, may produce cerebral embolism, (e) With a patent foramen 
ovale, thrombi may reach the brain from the venous system; it has 
been observed in manual expression of the placenta. (/) Most cases 
occur in youth (and middle age) when acute infections are most fre- 
quent, as chorea, scarlatina, or endocarditis. 

Pathology. — (a) The embolus in fresh cases is reddish, or gray-red, 
and later becomes paler, drier and more friable. There are often 
"riding emboli," which straddle the point of arterial branching; 
they may in rare cases soften and disappear, or by slipping produce 
another embolism further on (Laborde). Secondary thrombosis may 
occur at the infarction, (b) The artery beyond, save where the embolus 
retracts or softens, becomes a thin, hard, impervious cord. Behind 
the plug an aneurysm may form. If the embolus is septic, inflam- 
mation intervenes in and around the vessel, (c) The fate of the 
brain tissue depends wholly on (i) the degree of occlusion, and (ii) 
the collateral circulation, (i) If the stoppage is partial, only stasis, 
oedema and swelling occur; if total, necrosis results, (ii) The brain 
arteries are "end arteries/' as Cohnheim pointed out, whence complete 
collateral circulation is unlikely, although the necrosis is rarely as 
extensive as the distribution of the artery occluded, even where, as in 
the basal ganglia, the anastomoses are few. There is more chance 
of collateral compensation at the cortex than at the base, and the 
least collateral compensation occurs in the deep parts of the centrum 
ovale (Duret and Heubner). The brain tissue is ischemic, or its 
blood is venous (Marchand). The collateral vessels (arteries or 
venules) allow regurgitation around the focus, the vessels become 
more pervious, and some white and red cells often escape; this col- 
lateral fluxion saves the tissue more often than is usually admitted, 
especially if the heart is strong. With a weak heart or diseased col- 
lateral arteries, ischsemic necrosis must follow. Some pathologists 
hold that shutting off of a large bloodvessel raises the tension in the 
adjacent (collateral) vessels, and thus causes the small capillary 
hemorrhages often observed; but a marked hemorrhagic infarct is 
not common, for it is prevented by swelling of the nervous tissue. 



CEREBRAL EMBOLISM 981 

(Weigert). Much extravasation follows occlusion of a large vessel, as 
the internal carotid. Ischaemia lasting a few hours probably produces 
necrosis (Brieger and Ehrlich) but microscopic changes are seen only 
after one or two days; the brain substance becomes cedematous, 
gelatinous, grayish, marbled, fusing with the slightly cedematous brain 
tissue surrounding the focus, without clear demarkation; necrosis 
develops rapidly, the brain becomes fluid and pulpy, although its 
remarkable cohesion is a matter of frequent comment. The gray 
matter contains yellow plaques (v.i.); certain convolutions may waste 
or disappear; the gray and white substance, especially after plugging 
of the posterior cerebral artery, may wholly disappear, as the hippo- 
campus, lingual and fusiform lobules. The white matter often dis- 
appears, and is replaced by lax cellular tissue, in whose meshes are 
cystic formations with turbid fluid, and flocculi of brain tissue. The 
meninges are often thickened. Durand-Fardel described three forms 
of softening: (a) The red softening is usually fresh and is found most 
often in embolism; there is capillary extravasation, which lends it 
the red color; it is irregularly oval, or wedge-shaped in basilar lesions; 
it usually measures but a centimeter or two ; it is prominent on section 
from blood and serum; it is soft, but not fluid in the centre; is mostly 
located in the cortex or central ganglia, lasts one or two weeks, and 
then passes into the second form, (b) Yellow softening follows the 
red; the yellow color is due to old blood pigment or to fatty change; 
it is sunken on section, from atrophy of the brain substance; is fairly 
demarked and may contain fluid, hydrops ex vacuo; it may last years 
and is found especially in the cortex, (c) White softening may rep- 
resent (i) a fresh lesion about tumors (Bouveret) or abscesses, or in 
various cachexias, is sunken below the cut surface and occurs where 
few vessels are involved and little regurgitation from adjacent vessels 
occurs; (ii) lesions which are several years old, occurring when the 
blood and fat are absorbed, whence their snow-white appearance; 
demarkation is often slight, and if diffuse, gives rise to the spongy 
etat crible. 

Demarkation may occur after weeks, producing a "cyst" of spongy 
structure and milky contents. More rarely neurogliar increase may 
lead to shrinking, and a scar may result. Microscopically myelin and 
fat drops, leukocytes laden with granules and fat, collapsed vessels, 
relics of necrotic nervous tissue and some increase in neuroglia are 
observed. Location of eihbolism will be considered under Symptoms. 
Secondary degeneration occurs when the pyramidal tracts are involved 
(see Hemorrhage). 

Symptoms. — As in apoplexy, we consider (1) the insult, and (2) 
the permanent symptoms, to which might be added the symptoms of 
the causal disease, e.g., those of mitral stenosis, etc. 

1. The insult is almost always (a) sudden and without prodromes 
(save when the embolism does not wholly occlude the vessel, and 
symptoms appear only when secondary thrombosis develops). Em- 
bolism in small vessels may occur without symptoms. The patient 



982 



DISEASES OF THE NERVOUS SYSTEM 



may be stricken without coma, and sit " astonished" at the stroke, 
without a cry or even vertigo. The insult is caused by brain an&mia, 
negative pressure and shock (the etonnement cerebrate of Trousseau and 
Jaccoud); Geigel's idea that the rest of the brain is collaterally con- 
gested is less plausible. In some cases (b) coma occurs (generally 
less profound and less protracted than in hemorrhage); irritative 
symptoms, as (c) convulsions, tonic spasms and conjugate deviation 
are more common; convulsions are often unilateral, corresponding 
with the hemiplegia, {d) All possible intermediate types of focal dis- 
ease are observed; for instance, cases with vertigo; tendency to fall 
to one side; hemianopsia, alexia, hemiansesthesia, motor or sensory 
aphasia, or only confusion, delirium and aphasia (Fagge). (e) The 
pulse is full but not sloiv. (/) The temperature rarely suffers initial 
depression, and later may rise. 

2. The permanent symptoms and secondary degeneration are the 
same as in hemorrhage. 

Localization of Embolism. — 1. The artery of the fossa of Sylvius is 
most frequently involved (80 per cent.) because it is the largest and 

Fig. 58. 




Embolism of artery of the fossa of Sylvius 

IC, internal carotid; PC, post, communicating; AC, anterior cerebral artery; AS, art. fossa? Sylvii 
and 1, 2. 3, 4 and 5, its main branches. CR, corona radiata from cortex to internal capsule. 
(See text for explanation of lesions at A, B, C, D, E, F or G.) 



CEREBRAL EMBOLISM 983 

most direct branch of the middle cerebral which is practically a con- 
tinuation of the internal carotid. Convulsions occur in 33 per cent., 
with or without loss of consciousness, and are most frequent when the 
smaller branches are embolized. High temperature is common. The 
clinical picture varies with the site of infarction: embolism at A 
(Fig. 58) where the perforating branches (P. P.) are given off to 
the internal capusle, corpus striatum and anterior part of the thalamus, 
must involve (a) these structures, and (b) the motor and sensory 
cortex, with hemiplegia, fairly complete hemiancesthesia, motor aphasia 
(alexia), deafness and word deafness (if it occurs on the left side). 
Convulsions are absent, because the injured internal capsule cannot 
convey the cortical irritation to the extremities; the large areas at 
the base and cortex thus rendered anaemic, may cause marked reaction 
(Huguenin), sometimes resulting in death. In rare cases only the 
central perforating branches are involved and the cortex obtains the 
blood by anastomoses with the posterior and anterior cerebrals. The 
left Sylvian artery is more frequently involved, because the left carotid 
comes directly from the arch; 59 per cent, are left-sided (Gelpkel), or 
51 per cent. (Thenevet). If the lesion is at (B), (Fig. 58), the motor 
speech area, F3, which produces motor aphasia, the anterior and 
posterior motor convolutions (A.C.C. and A.P.C.) which produce 
hemiplegia or hemiparesis, the parietal convolutions, gyrus angularis 
and gyrus supramarginalis (P2) which produce alexia, and the tem- 
poral convolutions (Tl and T2) which produce deafness or word 
deafness, are involved. Somnolence and delirium are common; con- 
vulsions almost invariably occur, because the internal capsule escapes. 
Convulsions and pain are most frequent in embolism of the smaller 
vessels. Little hemianesthesia is observed (see Cortical Localiza- 
tion). A lesion at (C) is the most frequent site. It affects the island 
of Reil (LR.) in part; cortical convulsions, hemiplegia, monoplegia, 
sensory aphasia (Tl, T2), alexia (P2) and, sometimes sensory dis- 
turbance occur. It is easily seen how an isolated lesion at (D) could 
produce motor aphasia; at (E) a monoplegia; at (F) alexia; or at 
(G) word deafness. 

2. Embolism of the posterior cerebral (in 2 per cent.) comes from 
the vertebral artery, and often occurs with embolism of the Sylvian 
artery. It supplies (a) all the ventricles, the thalamus, ant. corp. 
quadrigemina, the geniculate body and the peduncle by its central 
branches, and (b) the mesial aspect of the occipital, part of the parietal, 
and most of the temporosphenoidal lobes. The most common general 
symptoms are convulsions, coma, vertigo, conjugate deviation and 
nystagmus; while the most important focal symptoms are sensory 
hemianesthesia , sensory aphasia and bilateral homonymous hemi- 
anopsia. The lesions are sometimes symmetrical. 

3. Embolism of the anterior cerebral artery: Few clear cases are 
recorded, since the artery originates at a right angle to the carotid. 

4. In embolism of the internal carotid (in 4 per cent.), the plug must 
be large to produce much damage, for if the vessels of the circle of 



984 DISEASES OF THE NERVOUS SYSTEM 

Willis are normal, only transient hemiplegia results. Disease of these 
vessels, or abnormalities in size, may produce permanent, alarming or 
fatal results. Secondary thrombosis is especially dangerous. Sepsis 
is a frequent factor. 

5. Embolism of the basilar artery occurs in 6 per cent.; the clot 
never fills the vessel, because it first passes the smaller vertebral 
artery; symptoms occur less frequently at the time of embolism than 
later when secondary thrombosis occurs. They are convulsions, 
trismus, paralysis of the third, fifth, and seventh nerves, crossed 
hemiplegia, diplegia, narrow pupils and conjugate deviation. The 
temperature often falls low and then rapidly rises. Death may follow 
in two to five days from respiratory failure. 

6. In embolism of the vertebral artery, involvement of the tongue, 
larynx, lips, pharynx, spinal branch of the fifth nerve, result in anes- 
thesia, dysphagia or other signs of acute bulbar palsy. Hemianes- 
thesia, hemiplegia, and hemiataxia may develop. It is often fatal. 

7. Embolism of the cerebellar arteries is the rarest of all embolisms. 
Diagnosis. — The main points are (a) recognition of the cause, 

which is usually cardiac; (b) absence of prodromes; (c) sudden insult, 
frequent convulsions, and infrequent coma. (For details and differen- 
tiation, see table under Thrombosis.) 

Prognosis. — The outlook depends (a) on the primary disease, being 
most favorable after acute infections, and in youth; (b) on the intensity 
of the onset itself, during which death may occur; (c) on the localiza- 
tion; the initial symptoms may improve; the outlook is more favorable 
than in hemorrhage. Psychical symptoms are cortical in origin, 
while the vegetative or trophic are due to lesion in the basal ganglia; 
basilar and vertebral embolism are most unfavorable prognostics. 
(d) Recurrence is possible, although it is less likely than is usually 
stated, (e) The condition of other organs, as the vessels of the circle 
of Willis, the strength of the heart muscle, etc., determine the prognosis. 

Treatment. — (a) The insult is treated as in hemorrhage, in regard 
to diet, keeping the patient quiet, and general measures, (b) All 
derivative measures, as drastics and venesection, are absolutely to 
be avoided, (c) The heart must be steadied and stimulated, if hemor- 
rhage is clearly excluded, with a view first, of relieving the brain 
ischemia by a strong collateral circulation, and second, of strength- 
ening the heart to avoid recurrence. Digitalis acts too slowly, and 
camphor, strychnine and ammonia are preferable, (d) Convulsions 
should be treated by chloral given by rectum, avoiding alcohol and 
supporting the heart. The administration of more than a dram of 
chloral in three hours is very dangerous; gr. x to xv should be given 
forty-five to sixty minutes apart, (e) The after treatment is unsatis- 
factory, but should be followed out as in the corresponding stage of 
apoplexy. 



CEREBRAL (ARTERIAL) THROMBOSIS 985 



VI. Cerebral (Arterial) Thrombosis. 

Thrombosis is more common than embolism. Three decades ago 
it was thought that fibrin was thrown out of the circulating blood by 
a ferment. Virchow held that slowing of the current was the chief 
cause, while Zahn, Weigert and others attributed great importance 
to coagulation necrosis of the leukocytes. Bizzozero, later also Ebert, 
and Schimmelbusch held that the blood plaques played a large part 
in coagulation. Brucke taught that the living healthy vessel prevented 
coagulation. 

Etiology and Pathology. — 1. Changes in the Vessel Wall. — (a) 
Arteriosclerosis (q.v.) is the chief cause of this most important group. 
It affects the basal arteries especially and usually several vessels. 
Blood plaques are deposited on the rough intima (Aschoff, Sahu), and 
in the tortuous, inelastic, calcarious, fatty vessels, with their unequal 
calibre; layer after layer of fibrin is deposited, aided by local slowing 
of the blood stream, and by weakening of the heart. Thrombosis 
may be local or extensive. Tumors, abscesses, and traumatic menin- 
gitis may initiate thrombosis. Brain atheroma usually occurs with 
general atheroma (see Arteriosclerosis). The vessels most involved 
are, in order of frequency, the carotid, middle cerebral and its Sylvian 
branch, basilar, vertebral and posterior cerebral, (b) Syphilitic end- 
arteritis occurs in young subjects, 84 per cent, being found in persons 
between the twentieth and fortieth years. The initial proliferation 
may of itself, without thrombosis, obliterate the vessel lumen (see 
Brain Syphilis). The pathological sequence is the same as in 
embolism; ischamiia, necrosis (softening) and loss of function occur, 
save that in gradual thrombosis the focus is necessarily less homoge- 
neous than in the sudden lesion of embolism. The foci are more 
often multiple, for example, in the Sylvian artery and in the posterior 
cerebral vessel of the opposite side. 

2. Changes in the Heart. — Sudden cardiac insufficiency in arterio- 
sclerosis may precipitate thrombosis, as brought out especially by 
Kolisko. An acute infection in the aged, low arterial tension from 
exhaustion, grief and similar causes may produce it when the arteries 
are ripe for encephalomalacia. 

3. Changes of the Blood. — This constitutes the smallest class of 
cases. Burns, poisoning by carbon monoxide and illuminating gas, 
gout, chlorosis, pregnancy, leukaemia, metallic poisons, jaundice and 
marasmus in very young children or in extreme old age may cause 
thrombosis. Mechanical factors, acute infections and heart weakness 
are frequent factors in this class. Malarial thrombosis might possibly 
be included. Thrombosis affects the smaller vessels and is usually 
multiple. 

Symptoms. — In some cases thrombosis is found at necropsy without 
previous symptoms ("latency"). 



986 DISEASES OF THE XERYOUS SYSTEM 

1. Prodromes. — These are frequent, and may appear hours, days, 
and even weeks or months before focal symptoms develop. The most 
common are headache, which is severe in the syphilitic variety, vertigo, 
tingling, numbness and weakness in a limb or in one-half of the 
body, disturbance in sight, mental changes, defective memory, poor 
articulation, irritability, loss of appetite for work, change in character, 
and sometimes a tense pulse with weak heart. 

2. The onset varies; (a) an acute onset with insult is not frequent. 
If consciousness is lost, the coma is less severe and protracted than 
in hemorrhage; a "stroke" indicates thrombosis in one large or in 
several vessels. Conjugate deviation, flaccidity and paralysis are 
frequent during the coma. Consciousness is usually preserved in 
the syphilitic type. With acute onset the later course is usually slow. 
(b) The onset may be gradual. Layer after layer is added to the 
clot in this most frequent type, and strengthened heart action may for 
a time help the collateral circulation. When the heart weakens the 
clot increases and the collateral blood supply decreases, so that, after 
a step-like course of advance and regression, the final thrombosis 
with irreparable ischemia and softening results. The cardiac strength, 
the number and size of the vessels involved determine the acuity or 
chronicity of the course. Reaction may be marked, especially in the 
aged, (c) In the chronic or long latent variety, prodromes are absent, 
psychic alteration is apparent and focal symptoms are usually de- 
veloped. 

3. In the chronic stage, whatever the onset, focal symptoms as 
monoplegia, hemiplegia, hemianopsia or aphasia are common. Apo- 
plectiform seizures mark the advance of the process in new vascular 
areas. The motor or sensory paralysis, at first transitory, is prone to 
recur, and presents much the same picture as hemorrhage or embolism 
in their chronic stage. 

Localization. — It is impossible to determine the localization when 
multiple foci exist, as in the Sylvian artery of one side, and the posterior 
cerebral artery of the other; to the few reported cases, Senator adds 
one in which left-sided hemiplegia was associated with aphasia. The 
favorite sites are the cortical branches of the Sylvian artery and the 
branches of the posterior cerebral vessels. 

1. Sylvian Artery. — The most common cause of this localization is 
syphilis or atheroma. When the main trunk is involved, the same 
symptoms appear as in embolism, viz.: hemiplegia, aphasia, hemi- 
anesthesia, and hemianopsia with this modification; the local symp- 
toms are more severe in thrombosis, because other vessels are somewhat 
diseased; the general symptoms are less severe. Prodromes appear 
first as vasomotor changes and tingling, then hemiplegia possibly 
with delirium or loss of consciousness; the symptoms may improve, 
then there may be recurrence with aphasia, and coma. The course 
is a " step-like" progression and regression. Monoplegia is more 
common than in embolism, because thrombosis seeks the cortical 
vessels, whence the face and arm may be affected, aphasia may exist 



CEREBRAL (ARTERIAL) THROMBOSIS 987 

alone, or alexia, mind blindness or deafness. When the basal arteries 
are diseased, the vegetative functions are involved, that is, trophic- 
changes with involuntary evacuations occur (gdtisme). 

2. Anterior Cerebral Artery. — This artery is rarely totally occluded. 
A clot beyond the anterior communicating vessel often produces crural 
monoplegia with some paresis of the arm. Very gradual anazmia 
produces ivasting without softening; sudden anaemia produces soften- 
ing. The brain may atrophy three to seven ounces, with senile 
dementia, mania or hypochondriasis and though not strictly softening, 
its close arterial connection is obvious. The frontal lobes, especially 
below, present the "worm eaten" atrophy, with abundant hydrops 
ex vacuo. 

3. Posterior Cerebral Artery. — Thrombosis in this artery is fairly 
common and may result in hemiplegia alternans oculomotoria, hcmi- 
hypsesthesia, and hemianopsia with irregular defects in the crossed 
fields; optic changes vary accordingly as the optic radiation, cuneus 
or other parts are affected. 

4. Basilar Artery. — If the thrombosis is acute, the symptoms are 
like those of embolism. If slow, ophthalmoplegia may develop which 
is rarely lasting, or other motor paralyses, hemiplegia with alternating 
palsy of the fifth, sixth, and seventh nerves. 

5. Vertebral Artery. — (a) Acute bulbar palsy, with stormy symp- 
toms, which cannot be distinguished from embolism; or (b) subacute 
bulbar palsy, with respiratory difficulty, dysphagia, paralysis of the 
larynx, disturbed articulation, hemianesthesia or hemiplegia with 
crossed paralysis of the tongue may result from this localization. 

Diagnosis and Differentiation. — The prodromes, gradual onset and 
cortical location are most distinctive, although the analysis may be 
greatly confused and differentiation of complicating conditions in the 
heart, and kidneys may be wholly theoretical or impossible. (See 
Table, page 988.) Thrombosis maybe confused with brain tumor, in 
which the course is slower, stabile focal symptoms less frequent, irritative 
symptoms (headache, vomiting and convulsions) more frequent than 
permanent paralysis ; and choked disk, Jacksonian epilepsy and periodic 
psychical manifestations are frequent. In this connection, we may 
consider hemiplegia in the aged and Marie's les lacunes de disintegra- 
tion cerebrate; degeneration clefts occur, chiefly in the large basal 
ganglia, sometimes in the internal capsule or pons (25 per cent.), 
and but seldom in the centrum ovale (13 per cent.); there are usually 
several foci. Marie holds that the lesion is a rarefication (cavity 
formation) of the brain tissue due to chronic sclerosing encephalitis, 
without vessel occlusion. It is said to cause 90 per cent, of "insults" 
in the aged, which occur usually with partial paralysis; sometimes 
with aphasia, dysarthria or dysphagia; rarely with loss of conscious- 
ness; and never with sensory disturbance or contractures. The 
gait is the demarche d petits pas. The prognosis is fairly good; great 
improvement may occur and the patient may live eight to ten years 
though hemorrhage may intervene. 



988 



DISEASES OF THE XERYOUS SYSTEM 



Hemorrhage. 



Thrombosis. 



Embolism. 



(1). Predisposing etiology. Before After eightieth year more frequent Youth: hemorrhage practi- 
third year (glioma); 80 per cent.! than hemorrhage. Twentieth tol cally never in youth, 
after fortieth year. ! fortieth year syphilis (of which! 

84 per cent, occurs between 
these years). 

Miliary aneurysms; atheroma, and Weak irregular heart; fevers, Endocarditis (rheumatism, 
cardiac hypertrophy. cachexia. Atheroma, especially sepsis) especially mitral. 

syphilis, alcoholism, plumbism. Weak, fatty dilated heart. 

In heart disease Eichhorst 
found in 60 per cent, hem- 
orrhage and in 40 per cent, 
embolism. 
Heredity. Nephritis: cause in 33 Rare. Rare. 

per cent, "granular kidney." Rare. Rare. 

(2). Attack precipitated by heavy Low arterial tension; by sleep, By exertion, dislodging clot, 
meal, acute alcoholism, high grief, exhaustion, fatigue, 
art. tension (excitement, effort, 
shock) . 
(3). Prodromes unusual, unless Very common, mental irritabil- Absolutely none, 
from causal arteriosclerosis. ity, weak memory, headache,! 

vertigo, numbness, tingling,: 
weakness in extremities. 
(4). Insult: Usually sudden; with- Rarely acute onset, (unless in a Sudden, shorter and less 
out prodromata; long duration large vessel); usually gradual,! severe than in hemorrhage, 
(fatal if more than two days); especially in senile softening. Cause: negative pressure. 
Cause: positive pressure produc- If an insult, focal and general Slow insult only with see- 
ing brain anaemia. symptoms usually appear during ondary thrombosis. 

the coma. 
(5). I ntra-cranial pressure: "Pres- Xone. None (pallor rather than con- 

sure symptoms" present, poly- Pulse soft, weak. gestion). 

uria, albuminuria, glycosuria, 
red face,beating arteries.Cheyne- 
Stokes breathing; slow, hard 
pulse is the fundamental differ- 
ence (Brissaud); bruit de gallop 
speaks strongly for hemorrhage. 
Irregularity, if combined with 
strength not against hemorrhage. 
Pulse may be fast (Brissaud). 
(6). Temperature: Rectal temper- Initial depression, usually lasting. Temperature may rise high 

Seldom temperature unless le- at once without bad omen, 
sion in pons. More probably 
early reaction. Especially in the, 
aged. 



ature usually depressed at first . 
may fall till death. May rise 
later (infla mm atory reaction). 
Early rise (pons, medulla, gang- 
lia). Sudden rise of bad omen; 
rises before death. 



Temperature no absolute 
guide: occurs especially 
when large trunk embolized. 



(7). Coma: More frequent, greater Less frequent and shorter. Re- No coma usually 



in degree, longer in duration, 
usually complete. If lesion seems 
small, coma speaks for hemor- 
rhage. Deep and prolonged 
speaks for hemorrhage and usu- 
ally fatal if over twenty-four 
hours. 



covery possible after several 
days of coma. Xone in syphilitic 
thrombosis. If lesion seems 
large consciousness speaks for 
softening. If coma, usually focal 
symptoms are then seen. Coma 
in large bilateral lesions. 

(8). Paralysis, sudden, complete. Gradual, incomplete, monoplegia, More like hemorrhage. Mono- 
hemiplegic, non-progressive after hemianopsia; repeated, often plegia rare. In 63 per cent. 
first seizure. Foot gains more symmetrical paralysis. , it is in the left side of the 

rapidly than hand. Persistent Converse. brain, 

aphasia exceptional. Spasmodic Aphasia common. Absence of focal Fairly common, 
laughing and weeping common. symptoms rather more com- 
mon (central ganglia). Laugh- 
ing and weeping exceptional. 
(9). Convulsions: Usually general- Less than in embolism. More More common (33 per cent.) 
ized; very rare from cortical irri- localized, Jacksonian epilepsy than in hemorrhage or 
tation or in corpus striatum; speaks for softening. May re- thrombosis (lesion corti- 
post hemiplegic are rare. j cur. Postplegic frequent. ; cal). 

(10). Sensation: Anaesthesia usu- Paraesthesia persists and more 

ally transient. \ marked. Cerebral pains (hyper- Ditto. 

; sssthesia dolorosa). 
Postplegic chorea, trembling, Less common. 

athetosis, common. 
(11). Atheroma retinal arteries. Arteriosclerosis, 
hence retinal hemorrhage (not 
significant unless large). Aneu- 
rysms very rare but speak 
strongly for hemorrhage. Ret- 
initis albuminuriea. 
(12). Secondary reaction; not much. Greater secondary reaction. 

Psychical symptoms; far less. Often greater: intelligence, mem- 
ory aphasia, word deafness, etc. 



Less common. 

Optic retinitis sometimes 
from endocarditis (Broad- 
bent and Mackenzie). 

Occasionally embolism in re- 
tinae. 



Very seldom ; after attack 
may be some delirium. 



INTRACRANIAL ANEURYSMS 989 

Prognosis. — The prognosis depends on (a) the cause. It is unfavor- 
able in arteriosclerosis, because collateral vessels are probably diseased 
and the cause is progressive. If the other vessels are sound, enormous 
disease may be compensated, as in KussmauTs case of occlusion of 
both the subclavian and carotid. In cases of recent syphilis the prog- 
nosis is more favorable, though old specific thrombosis is incurable. 
The younger the patient, the better is the outlook, (b) It also depends 
on the onset. A brusque beginning is unfavorable, because most cases 
of this class die (Durand-Fardel). Coma indicates thrombosis in 
large vessels or in both hemispheres, and is therefore ominous. If 
there is no insult, the focal symptoms are usually irreparable, i.e., 
there are no indirect symptoms. The first seizure does not usually 
threaten life, (c) The location and extent of the lesion. The number 
of vessels involved is obviously important. In Sylvian thrombosis 
involving the branches to the central ganglia, cachexia and more 
trophic disturbance occur and the patient dies in four to six weeks, 
with involuntary evacuations and bed-sores (Marie). Cortical lesions, 
on the other hand, are more prone to produce psychical alteration. 
Basilar or vertebral thrombosis are directly dangerous, (d) The focal 
symptoms are likely to persist and recur. Ophthalmoplegia may regress. 
(e) The condition of other organs, above all that of the heart, is of 
prognostic import. 

Treatment. — (a) The general treatment is the same as in hemor- 
rhage and embolism, (jb) The causal treatment relates to the iodides, 
which are of value in atheroma (lessening the viscosity of the blood) 
and are specific in early syphilis, (e) The heart must be stimulated 
with strychnine, digitalis and strophanthus ; absolute quiet in the 
prone position, and free administration of food and fluid by rectum 
and by nasal catheter, are indicated. Drastics and all depleting 
measures must be avoided. On the heart devolves the entire pos- 
sibility of collateral compensation, (d) In the period of reaction, 
alcohol should be avoided, for it accentuates the inflammatory reac- 
tion. For delirium and headache, bromides are most useful; 
no cardiac depressants, chloral or coal-tar products may be used. 
(e) The chronic stage is treated as in hemorrhage. At all times 
catheterization must be conducted antiseptically and great care exer- 
cised against bed-sores. In the use of baths, massage and electricity, 
treatments short of producing fatigue are indicated. 



VII. Intracranial Aneurysms. 

Etiology. — Aside from miliary aneurysms, aneurysms may occur in 
the large brain vessels. They are seen in 0.2 to 1 per cent, of autopsies. 
They are more frequent in males (60 per cent.) and in middle age, 
although they may visit either extreme of life and a few more (53 per 
cent.) occur before than after the fortieth year. The causes are those 
of aneurysm elsewhere (q.v.); they are (a) atheroma in whose causa- 



990 DISEASES OF THE NERVOUS SYSTEM 

tion alcohol is particularly important; (b) trauma, initiating arteritis, 
especially in the internal carotid, as after basal fracture (Killian); 
(c) syphilis especially productive of basilar aneurysm, which often 
occurs -within a year after infection; (d) embolism, the most frequent 
cause in early life. Endocarditis is the usual cause when trauma and 
syphilis are excluded (Lebert and Church). The embolus produces 
arteritis from which the vessel dilates. The clot may later disappear. 
The Sylvian vessel is most frequently involved. 

Pathology. — Location, — The statistics of Lebert, Durand, Bartholon 
(collected by Growers), and Osier combined show the following fre- 
quency: middle cerebral, 29 per cent.; basilar, 26 per cent.; internal 
carotid, 14 per cent.; anterior cerebral, 8 per cent.; anterior com- 
municating, 6 per cent. They are somewhat more frequent on the 
left side, in 20 per cent, are multiple, are usually sacculated, of the 
size of a pea or walnut (rarely large as an egg), and are genuine aneur- 
ysms involving all coats. 

Symptoms. — Symptoms may be absent until rupture occurs. They 
are (a) general, as headache, which is the most common sign, or con- 
vulsions, which result from aneurysm of the Sylvian branch; optic 
neuritis is rare; a systolic murmur, neuralgia or epileptiform seizures 
may be noted. (6) They may be local; according to their location, 
hemianopsia, paralysis of the ocular nerves, impairment of smell, 
hemiplegia, optic neuritis (extension of inflammation from the sac), 
aphasia, and symptoms referable to the pons or medulla may be noted. 
Rupture occurs in 75 per cent, of cases; (i) into the meninges or (ii) 
into the brain substance or ventricles, from which death results in a 
few hours or days; healing has been observed. 

Diagnosis. — Rupture is often the first symptom, and differentiation 
from hemorrhage is therefore necessary. A general cerebral hemor- 
rhage in a young individual, with a history of trauma, heart disease 
or syphilis, is rather suggestive of aneurysm, especially when the loca- 
tion is basilar. If symptoms have been present, they are often those 
of a basal tumor; syphilis (q.v., Cerebral Syphilis) and trauma are 
causes of tumor and aneurysm, but iodides and mercury usually are 
not beneficial in aneurysm. The murmur is suggestive but is rare 
and may be found in tumors wmich compress vessels or in very vas- 
cular brain tumors. The location of the aneurysm is important; 
they are most often embolic in the Sylvian, and specific in the basilar 
artery. Loss of sight in an eye, sometimes with impairment of smell' 
rather indicates aneurysm of the anterior cerebral or, if the eye muscles 
are paralyzed, of the internal carotid artery. Oculomotor paralysis 
without loss of vision suggests aneurysm of the posterior communi- 
cating artery. Some cases closely resemble arterial thrombosis. 

Treatment. — The indications are the same as in aortic aneurysm 
(q.v.) viz., rest and iodides. Surgical intervention is occasionally 
opportune, as ligation of the carotid. 



SINUS THROMBOSIS 991 



VIII. Sinus Thrombosis. 



The marantic form was known to the oldest authors, while Aber- 
crombie, von Dusch and Bright described the pysemic form. Lebert 
(1854) diagnosticated the first case and with Tonnele built up its 
clinical recognition. 

Etiology and Pathology. — There are two varieties, in which prac- 
tically all cases can be placed, (1) the marantic and (2) the inflam- 
matory types. 

1. Marantic thrombosis of the sinuses and veins is the primary non- 
inflammatory, type, due to altered blood states and weakened circu- 
lation. It occurs (a) in children mostly, especially in the first six 
months of life, and after acute infections, but particularly after infective 
diarrhoeas; (b) less frequently in the aged from weak heart and venous 
stasis; (c) in cachexia, from cancer, gout and tuberculosis; (d) in 
the anaemia of pregnancy and in chlorosis (Sollier, Bollinger, Konig, 
Bucklers and Kochel); (e) compression of veins or sinuses as by tumor, 
is rare. Its most frequent site is the superior longitudinal sinus, 
especially in children, because the sinus is fixed, its lumen is triangular 
and irregular, crossed by trabecular and compressed, by the Pac- 
chyonian granulations; the tributary veins empty against the current 
of the sinus, the veins ascend and their stream is very weak. Gowers 
believes that thrombosis in veins entering the superior longitudinal 
sinus may cause hemiplegia in children. Experimentation seems to 
show that simple slowing of the current is not sufficient for coagulation, 
and that the vessel wall must be altered; Bollinger holds that in chlo- 
rosis there is fatty degeneration of the endothelium. In the aged, 
marantic thrombosis rather elects the cavernous or transverse sinus. 
The older the antemortem clot, the lighter is its color, and the more 
laminated and adherent it is to the sinus wall, wherein it differs from 
the reddish, loose and separable postmortem clot. The marantic 
clot may be total, occluding the vessel, or may be partial. It may be 
short, or may fill the whole sinus and enter the tributary veins which 
are then seen as firm cords over the hemispheres. 

2. The inflammatory thrombosis , thrombophlebitis , is secondary to 
disease near the sinus; as (a) ear disease, chiefly chronic, sometimes 
acute, suppurative otitis media, caries of the bone (Fuchs), sometimes 
syphilis, tuberculosis or cholesteatoma. Infection from the ear reaches 
the sinus by (i) infecting the mastoid cells, which infect the transverse 
sinus; (ii) by the passage of the virus from the middle ear to the 
sinus by infecting small communicating veins (Politzer) or (hi) its 
passage along the petromastoid canal (Voltolini). In S1,64S ear 
cases reported by Hessler, 116 fatalities occurred, of which 34 per 
cent, was meningitis. It may be secondary; (b) to acute infections, 
with otitis media; (c) to sepsis, puerperal fever, pyaemia; (d) to trauma, 
tuberculous meningitis, erysipelas, disease of the orbit, nose, gums, 
and face. The most common sites are the transverse, petrosal and 



992 



DISEASES OF THE XERVOUS SYSTEM 



cavernous sinuses, whence it may extend to their branches. The clot 
is puriform, foetid, soft, discolored and contains pyogenic organisms; 
the process is frequently associated with meningitis and brain abscess. 

In both types, brain changes may result, as oedema, swelling or 
softening of the cortex. Most frequently the thrombosis is bilateral; 
suggillations in the pia, bloody imbibition of the brain or reddening 
of the cerebrospinal or ventricular fluid may occur. Pulmonary 
infarcts occur in 50 per cent., and are simple or septic according to 
the type of thrombosis. 

Symptoms and Diagnosis. — Clinical signs may be absent or ob- 
scured by the primary affection. Diagnosis depends upon signs of 
(1) extra- and (2) intracranial venous stasis. 



Fig. 59. 




COMMUNICANS WITH THE NECK 



Diagram showing the connections* of the transverse and cavernous sinuses (Leube). 

1. Extracranial Stasis. — (a) In thrombosis of the superior longi- 
tudinal sinus, stasis in the nasal veins is often shown by epistaxis 
(connection through the foramen caecum) : this was first observed by 
von Dusch. It is an effort of nature to deplete the cerebral congestion. 
Gerhardt observed cyanosis in the anterior frontal veins and cedema, 



SINUS THROMBOSIS 



993 



especially in children, in the temples between the great fontanelle 
and ear (by way of the emissaria Santorini through the foramen 
parietale). * (Edema is often absent in chlorotic thrombosis. Sweats 
over the forehead, head and neck (Fritz) are of uncertain diagnostic 
value, (b) In thrombosis of the cavernous sinus, stasis develops in its 
tributaries, producing exophthalmos, oedema of the lids and conjunctiva 
(vena ophthalmica) ; retinal stasis, more rarely choked disk (Milligan) 
or retinal thrombosis (Bouchut), results from congestion of the vena 
centralis retina?. Sometimes oedema of the forehead results from 
stasis in the vena facialis ant. Epistaxis is rare (Stager), (c) In 
thrombosis of the lateral sinus, a hard, tender oedema behind the 
ear (Griesinger) and in the neck (communicating with the posterior 
auricular vein) occurs in over 50 per cent, of cases. Occasionally 
the swollen thrombotic internal jugular vein may be felt. The external 



Fig. GO. 



VEINS COMMUNICATING THROUGH 
THE PARIETAL FORAMEN WITH 
THE EXTERNAL SKULL VEINS. 




VENA JUGULARIS EXT. 



Leube's diagram showing the connections of the superior longitudinal sinus with the 

external veins. 



jugular frequently collapses, or if the internal jugular is thrombosed, 
it becomes overfilled (Gerhardt). In 33 per cent, the disk is hyper- 
semic, and in another 33 per cent, there is choked disk (Jansen) 
from complicating abscess or meningitis, (d) In thrombosis of the 
sinus petrosus, the signs are conflicting and Gowers questions whether 
any are distinctive. 

2. Intracranial Stasis. — Progressive clouding of the mind, delirium 
in adults, convulsions in children, conjugate deviation of the eyes and 
head, stiff neck, vomiting, headache, irregular pupils, nystagmus or 

63 



994 DISEASES OE THE NERVOUS SYSTEM 

strabismus are noted. Hemiplegia and sensory symptoms are occa- 
sional. Bilateral symptoms, as paraplegia, are due to the involvement 
of the veins in both hemispheres or more often to meningitis. Bouchut 
thought that antemortem convulsions in children were often throm- 
botic in origin. It will be seen that many of these symptoms resemble 
the hydrencephaloid (Marshall Hall) of brain anaemia. The fontanelles, 
sunken at first in infantile diarrhoea, may later become prominent 
(increased cerebrospinal fluid). Sometimes in chlorotic thrombosis the 
process may extend to the vena Galeni magna, producing hydro- 
cephalus internus and resulting in early stupor, coma and death. 
Irritation or paralysis of the third, fourth, and sixth nerves may occur 
because of their intimate relation to the cavernous sinus; involvement 
of the first branch of the fifth nerve may result in ophthalmia neuro- 
paralytica. Rarely is there paralysis of the hypoglossus and spinal 
accessory. 

Other symptoms are those of the causal affection. The temperature 
is often normal in the simple variety, or high in the death agony. The 
pulse is slow at first and rapid later. The thrombophlebitic variety 
is usually attended by fever, chills, sweats, diarrhoea and other septic 
manifestations. 

Differentiation from meningitis (q.v.) and brain abscess (q.v.) is 
often impossible; the cause, the extracranial stasis, and evidences of 
sepsis are of diagnostic importance. Korner held that metastases 
occur in the lungs from sinus thrombosis and in the bones and joints 
from mastoid caries. 

Prognosis. — The prognosis is almost always unfavorable; death 
occurs in the second week, or possibly later. A few recoveries from 
both types are on record. Local atrophy of the brain has resulted 
after recovery from the marantic type. 

Treatment. — Prophylaxis relates chiefly to the otitic variety, because 
discharges from the ear are much too lightly regarded by the laity. 
In marantic thrombosis stimulation and avoidance of constriction of 
the neck are the chief indications. In septic types operation is indi- 
cated; recovery is most likely when there is early diagnosis and early 
operation. Opening and packing the lateral sinus was first performed 
by Zaufal in 1884. He also recommended ligature of the jugular 
vein, which was first performed by Thersley and Lane in 1888. Re- 
covery occurs in 50 per cent, of operated cases and in 72 per cent, of 
Macewen's series. Recovery has occurred even with complicating 
lung abscess (Ballance). Gravitating pharyngeal abscess and extra- 
dural foci also necessitate surgical interference. 



IX. Infantile Cerebral Paralysis. 

Cerebral infantile palsy is classed under circulatory diseases because 
of the frequent etiological hemorrhage, embolism and thrombosis. 
Pathologically it is sometimes described under encephalitis, sclerosis 



INFANTILE CEREBRAL PARALYSIS 995 

or porencephalia. Clinically it is variously classed according to the 
dominant syndrome, hemiplegia, diplegia, Little's disease, paraplegia, 
hemiathetosis, and athetosis. The disease is a clinical picture, but 
with varying etiology and pathology. Osier, Sachs, Strumpell, Freud 
and Rie have contributed most valuable monographs. 

The Hemiplegic Form. — Etiology. — It is equally frequent in either 
sex. Most cases occur in the first year. Gowers finds 60 per cent, 
in the first two years, 75 per cent, in the first three and 88 per cent, in 
the first five years of life. Infections, as scarlatina, measles, less fre- 
quently variola, pertussis, or diphtheria are apparent, and heredity, 
maternal syphilis or trauma are doubtful, causes. The causes may 
operate before, during, or after birth. The pathology is considered 
under the next type. 

Symptoms. — (a) Initial symptoms, present in 66 per cent., are 
severe in character, consist of fever, vomiting, convulsions, delirium 
and coma, and last from a few hours to several days, sometimes longer. 
Convulsions, present in 50 per cent., are often unilateral and are usually 
followed by coma. In 33 per cent, of cases the onset is insidious, (b) 
The paralysis (hemiplegia) usually develops when consciousness re- 
turns. It is more frequently right- then left-sided. The lower face 
is involved, but usually soon improves, the leg improves more than 
the arm and hand, and the paralysis, at first flaccid, soon becomes 
spastic and is usually permanent. In general it resembles adult hemi- 
plegia (See Next Stage). Sometimes the eye muscles are involved, 
and hemianopsia may be noted. Although the tactile and stereognostic 
sense may be somewhat reduced, sensation is but slightly implicated, 
because the other hemisphere compensates, (c) The residual symp- 
toms are the same as in adults, with some exceptions; the paralysis 
is spastic (spastic infantile hemiplegia, Heine) but also atactic and 
athetotic. Because is occurs in the young growing body and brain, 
marked trophic changes or, at puberty, retarded development appear, 
intellection is retarded or actual idiocy results, and epileptiform seizures 
are common. Contractures are frequent, the reflexes are increased, 
and the gait is somewhat impaired, the foot dragging. In rudimentary 
(formes frustes) or benign cases, the paralysis may almost disappear 
and, after months or years may be so replaced by epileptic seizures, 
hemiathetosis, hemichorea, hemitremor (described under hemorrhage) 
or hemihypertonia (rigidity with but little paralysis) that the paresis 
readily escapes recognition. Aphasia is rarely lasting. It must be 
recalled (a) that reflex aphasia is very common in childhood from 
fever or digestive difficulties; (b) that the brain readily compensates 
in childhood; (c) that permanent aphasia indicates great or total loss 
of intelligence. Trophic changes are in part a moderate atrophy and 
in part lack of later development, though seldom so marked as in the 
spinal type of paralysis. They are noted in the extremities, body, 
sometimes the face and in the skull which often thickens; they are 
most common in porencephalia (v. i.). Epilepsy increases in fre- 
quency after the paralysis, and is rated at from 13 per cent, to even 



996 



DISEASES OF THE NERVOUS SYSTEM 



66 per cent.; it occurs (a) at the onset, (b) with the paralysis, or (c) 
a year or two later; it is not commensurate with the degree of 
paralysis but is more marked in rudimentary palsy; it may be slight 
like a vertigo; it is most often like the Jacksonian type, but may end 
in total loss of consciousness. In infantile cerebral paralysis there is 
less violence, initial cry, trauma, foaming at the mouth, and fewer 
involuntary evacuations than in ordinary epilepsy. After a decade 
or more it often becomes very marked, although it has been known 
to disappear between the fortieth and fiftieth years. 

Diagnosis. — The chief differential interest centres in its separation 
from the spinal type (poliomyelitis): 



Cerebral Type. 


Spinal Type. 


Tendon reflexes. 




Increased. 


Decreased or abolished. 


Muscular atrophy. 




Only after a long time. 


Rapid. 


Electrical reaction. 




1 Normal, or little quantita- 
tive decrease. 


Partial or total reaction of 
degeneration. 


Distribution of pai 


alysis. 


iHemiplegic — diplegic. 


Chiefly monoplegic. 


Intelligence. 




1 Oft en involved. 

i 


Usually not. 


Epilepsy and hemic 


horea. 


Common. 

I 


Rare. 



The Double Hemiplegic or Diplegic Form. — Etiology. — (a) Pre- 
natal causes are apparent in 7 to 31 per cent, and include fright, 
trauma, malnutrition or syphilis of the mother. These causes seem 
most common in cases which develop athetosis, (b) Anomalies of 
labor, suggested by Little and proven to be as a factor by Sarah 
McNutt, include difficult or long labor, malpresentations, resistant 
maternal tissues, twin pregnancy, version, cord prolapse and instru- 
mentation, although delivery by forceps is less important than the 
causes calling for their use. Asphyxia is an important etiological 
factor. Premature delivery is also causal, possibly because the soft 
skull is injured (Gowers) or because venous stasis occurs from pre- 
cipitate delivery, (c) Extra-uterine causes are indefinite, and include 
trauma and acute infections. 

Pathology. — The pathology presents many obscure points. The 
initial lesion cannot always be determined, (a) In the traumatic 
class, meningeal hemorrhage causes 66 per cent, of the diplegic cases; 
Sarah McNutt found hemorrhage spreading over the motor cortex 
on both sides. It is promoted by asphyxia and the sliding of the skull 
bones of one side under or over those of the other side; hemorrhage 
is often basal in head presentations, and on the convexity in the after- 
coming head. The blood is absorbed slowly, especially if the brain 
is lacerated, resulting in atrophy of the motor areas of both sides; 



IXFAXTILE CEREBRAL PARALYSIS 997 

hemorrhage rarely results from hereditary syphilis. (b) Vessel disease 
(18 per cent.) may be arterial (thrombosis, embolism or hemorrhage) 
or venous (in the cortical veins, Go wers). (c) Strumpell advanced the 
views of Vizioli and Marie that acute encephalitis in the motor cortex 
(poliencephalitis) causes the acute onset, an argument largely based 
on analogy (poliomyelitis in children), though seldom verified. 

Chronic Lesions. — The most important are diffuse lobar sclerosis, 
and porencephalia, which are peculiar to infantile brain palsies: (a) 
Diffuse lobar sclerosis and atrophy of the brain occur in 55 per cent. 
(Osier). The meninges are normal or somewhat thickened. About 
the atrophic areas and in the ventricles the cerebrospinal fluid is 
increased. One or both hemispheres may be involved but usually 
unequally. The lobe affected is shrunken, hardened, leathery and the 
white matter is decreased, while the gray seems increased. The 
convolutions are much wasted and are smooth or "worm eaten." 
The nervous tissue is wasted, the neuroglia increased, and the blood- 
vessels tortuous, somewhat thickened and their perivascular lymph 
spaces widened five- or six-fold. The nature of the initial lesion is 
disputed; it is thought to be encephalitis (Bourneville), poliencephal- 
itis (Strumpell) and embolism, (b) Porencephalia (Heschl, 1859) con- 
sists of loss of brain substance, and cavity formation. It occurred in 
26 per cent, of Osier's cases. The nature of the initial lesion causing 
porencephaly is a matter of doubt; it is ascribed to anomaly of de- 
velopment (agenesis), inflammation (encephalitis or meningo-enceph- 
alitis), trauma (during labor or to the uterus during pregnancy) or 
anwmic necrosis (Kundrat); the latter is the most widely accepted 
view. It is most frequent in the distribution of the Sylvian or occipital 
vessels. Most often it is congenital and then the convolutions radiate 
from the defect, while in those cases resulting post natiim, the con- 
volutions stop short of the defect "as though cut off/' Bourneville 
and Sollier hold that the congenital type communicates with the 
lateral ventricle, while the acquired form does not. Sixty-six per cent, 
is bilateral and somewhat symmetrical, (c) The hypertrophic nodular 
sclerosis described by Bourneville consists of multiple discrete prom- 
inent, often umbilicated nodes, the size of a quarter or half-dollar. 
They are overgrowths of the neuroglia. 

Symptoms. — Diplegic cases are half as frequent as the hemiplegic. 
Freud describes the following forms: (a) General rigidity, or Little's 
disease, 33 per cent, of which is caused by asphyxia. The main 
characteristics are (i) predominance of the rigidity over the paresis, 
and (ii) predominance of the leg paresis over that of the arms, the 
converse of adult cerebral paralysis (hemorrhage occurs most often 
over the leg centres). Convulsions often usher in the symptoms, 
which appear after birth or a few months later. The rigidity is general 
but most conspicuous in the flexors and adductors, leading to unusual 
postures. The face is slightly involved, the maximum manifestation 
being spasm of the mouth; in rare cases the child cannot nurse or 
swallow. Speech is slow in development and stuttering is common. 



998 



DISEASES OF THE XERVOUS SYSTEM 



Fig. 61. 



In 33 per cent, the head cannot be lifted or the trunk flexed; this is 
due to involvement also of the uncrossed pyramidal tracts. The 
arms may be but slightly paretic, but the legs suffer extensor spasm 
on movement, and the toes turn down (talipes equinus or equino- 

varus). The child learns to walk late, 
if at all, because of the adductor rigid- 
ity, which may even cause crossing of 
the legs. The reflexes are greatly in- 
creased. The intellect is somewhat 
affected in 66 per cent., but nutrition 
in the paretic members is usually 
intact. Later epilepsy is uncommon. 
The paresis may regress and the 
mind improve, but the legs remain 
spastic. (b) Paraplegic rigidity re- 
sembles type (a) except that the arms 
are but little or not at all affected and 
the legs alone are rigid. The name 
Little's disease is also given to this 
form. Strabismus is common (40 per 
cent.). Premature delivery is a factor 
in 50 per cent, of cases, (c) Paraplegia 
is rare and is referred to extra-uterine 
causes or to infantile infections. The 
legs are rigid and paralyzed. In 
severe types there may be strabismus 
and imbecility. (d) While bilateral 
spastic hemiplegia (spastic diplegia) 
exists, the symptoms may vary on the 
two sides. Mental degeneration is fre- 
quent; nystagmus, convergent strab- 
ismus (25 per cent.), bulbar symp- 
toms (Oppenheim) and speech in- 
volvement (60 per cent.) are frequent, (e) General infantile chorea 
is also called "choreatic diplegia"; asphyxia is a factor in 25 
per cent. Its clinical characters are (i) paralysis, (ii) rigidity, (hi) 
chorea-like movements which are irregular, usually slight in degree 
and wide in distribution. (/) In bilateral athetosis, the mind is less 
involved than in the preceding types. The paralysis may precede it 
or it may be primary. 

Forms resulting from premature delivery are less subject to con- 
vulsions, athetosis or mental changes, and are more regressive than 
those due to birth trauma or later acquired lesions. (See Diseases 
of the Spinal Cord for the allied Family or Hereditary Forms, as 
Hereditary [Friedreich's] Ataxia). In all forms epilepsy may (i) 
replace the regressing paralysis; (ii) remain so prominent that the paral- 
ysis is overlooked ; (hi) paralysis may appear only after years of epilepsy, 
or (iv) may not appear at all, " cerebral paralysis without paralysis." 




Spastic paraplegia, cross-legged progres 
(Dercum.) 



BRAIN TUMORS 999 

Diagnosis. — The diagnosis cannot always be made at once, although 
later, characteristic symptoms develop and leave little diagnostic 
difficulty. Separation from the family spastic paralysis (q.v.) may be 
difficult' or impossible. As a rule, aside from disease of the spine 
which compresses the cord, confusing spinal cord disease is very 
rare in children. 

Treatment. — Therapy is most unsatisfactory. In the initial stage, 
convulsions may be treated by chloral or inhalation of chloroform. 
Some regression in the paralysis is frequent, but the hemiplegia, mental 
changes, and epilepsy are incurable. Marked improvement can be 
expected in the syphilitic cases alone. Orthopedic devices are valuable. 
The resulting epilepsy is usually intractable, and bromides are of 
little avail. Flechsig advises their use, in combination with opium. 
Operative interference has been suggested. Twenty-five per cent, die 
from the operation, but the surviving cases seem to improve, especially 
in regard to the convulsions. 



(C). BRAIN TUMORS. 

Etiology and Pathology. — Eichhorst found brain tumors in i of 1 per 
cent, of his cases. Sixty-six per cent, of tumors occurs in the male sex, 
especially glioma and tubercle, while sarcoma occurs equally in the two 
sexes. Age. In the first decade, 18.5 percent, of cases is observed; in the 
second, 14 per cent.; third, 20 per cent.; fourth, 18.5 per cent., and 
in the fifth, 14 per cent. (Gowers). The causation is that of neoplasms 
in general, as developmental errors, granulomata, metastatic growths, 
and parasites. Trauma is a certain but infrequent cause ; it may clearly 
cause growths, especial y glioma, but may act as the " agent 'provocateur' 
in gumma, sarcoma, osteoma, tubercle or aneurysm. The author has 
seen endothelioma of the dura develop years after and directly at the 
seat of an unhealed skull fracture. Syphilis may induce sarcoma. 

Classification. — Classification is difficult. 

1. The Infectious Granulomata. — (a) Tubercle constitutes 50 per 
cent, of cerebral tumors, 50 per cent, being found in the first, and 75 
per cent, in the first and second decades (Gowers). The subject is 
usually poorly nourished, and often exhibits lung changes; 33 per 
cent, occurs in the cerebellum, 33 per cent, in the cerebrum and the 
remainder in the pons, central ganglia, cms, medulla and corpora 
quadrigemina. With equal frequency they are single or multiple, and 
may number even 20 or 80. They originate from the meninges or 
vessels of the brain substance, and are firm, rather rounded tumors, 
with grayish-red periphery and yellow caseated centre. Tubercles 
range from the size of a pea or walnut to that of an egg or of the fist. 
from fusion of many small growths. They grow along the lymph 
vessels, cause vascular thrombosis, present the degeneration of tubercle 
of other tissues, and may be shelled out of the brain tissue, which is 
compressed and atrophied, but neither infiltrated nor softened. (6) 



1000 DISEASES OF THE XERYOUS SYSTEM 

Gummata (see Brain Syphilis) occur far more frequently than 
statistics indicate, for they respond to treatment and often disappear 
spontaneously. In the adult they are the most common type of 
tumor. They are most frequent in the cerebral hemispheres and 
pons, and are rare in the cerebellum and central ganglia. Though they 
are most often the size of a pea or hazelnut, larger dimensions are 
observed. Their centre is yellow-gray, and their periphery is reddish- 
gray, gelatinous, rich in cells and ultimately cicatricial. Gummata 
are usually multiple. The adjacent brain tissue is not infiltrated, but 
commonly softened and compressed. Microscopically they closely 
resemble tubercle, but Virchow described them as more nodose, 
angular, irregular, more distinctly connected with the dura even when 
deeply located, more gelatinous and less caseated. Tubercle bacilli 
are not always found in unmistakable tubercles, and gummata are 
sometimes miliary in size. Both forms have been confused with actino- 
mycosis. 

2. Neuro-epithelial Growths. — (a) Glioma constitutes 25 per cent, 
of brain growths; 50 per cent, occurs in the hemispheres, especially 
the cortex; 25 per cent, in the cerebellum, and the balance in the central 
ganglia, pons, medulla, crus, and corpora quadrigemina. They occur 
more frequently in the brain than in the cord or retina, to which three 
structures they are peculiar. Gliomata are usually (90 per cent.) 
single, and are seen most frequently in adults (first to twentieth year, 
20 per cent. ; twentieth to fortieth year, 50 per cent. ; fortieth to sixtieth 
year, 25 per cent., Gowers). Some classify glioma with sarcoma. 
Gliomata originate largely in the gray substance, which they so closely 
resemble in tint that detection is difficult at operation, or indeed at 
autopsy, where secondary hemorrhage or softening in them may be 
confused with primary hemorrhage. Cases formerly called brain hyper- 
trophy were probably gliomata. Their size varies from that of a pea 
almost to that of a hemisphere. Glioma infiltrates without sharp de- 
markation rather than compresses the brain tissue, and does not form 
adhesions. The cells resemble the neurogliar structure and usually 
have round or oval nuclei, although Klebs found ganglionic cells. Their 
processes are fine; numerous and branched delicate band-like lines 
result from fiber degeneration, (b) The rare cerebroma of Hay em was 
held by Virchow to be heterotopic gray matter in the white substance. 
(c) Adenoma of the pineal gland and hypophysis may be brought under 
this heading as also may (d) growths from the plexuses, and (e) neu- 
romata. 

3. Connective Tissue Tumors. — (a) Sarcoma is the most frequent, 
and constitutes 20 per cent, of brain tumors; it may develop in 
the meninges, periosteum or vessels. It is most common in adults. 
Though it infiltrates more than tubercles or gummata, it does so less 
than would be expected. Many are well demarked, and cause more 
softening than infiltration. Its structure and degenerations are those 
of sarcoma elsewhere. Though it is most commonly single, diffuse or 
multiple sarcomatosis is sometimes encountered. Endothelioma (Zieg- 



BRAIX TUMORS 1001 

ler), cylindroma (Billroth), angiosarcoma and melanosarcoma are but 
varieties. The sand tumors (psammomata) of the pineal gland, Pac- 
chyonian bodies and choroid plexus are sometimes described as angio- 
lithic sarcomata. The "pearly tumors" (cholesteatomata) are formed 
of flat endothelial cells, {b) Benign connective tissue growths (lipoma, 
fibroma, and osteoma) are very infrequent. 

4. Metastatic Tumors. — Cancer is not infrequent (7 per cent, of 
brain growths), especially from mammary or lung carcinoma, just as 
lung suppuration often secondarily involves the brain. It often invades 
the hemispheres and basal ganglia, and may attain huge dimensions. 
Like sarcoma, it infiltrates. Cancer is very rarely primary. 

5. Cystic Tumors. — Cysts may result from hemorrhage or softening, 
degeneration in neoplasms, infantile inflammations or defects (poren- 
cephalia), trauma, or inflammation in the choroid plexus. Dermoids 
and teratomata are most rare. Parasitic cysts occur largely in persons 
between the tenth and thirtieth years; echinococcus cysts may be 
single or multiple; they occur chiefly on the surface of the brain, or 
in the meninges, and vary much in size. Cysticercus cysts develop 
mostly on the pia and arachnoid over the cortex along the sulci, or in 
the ventricles. They occur in T 4 of 1 per cent, in certain autopsies, 
though Diamond (1899) could collect but 8 cases from the American 
literature; they vary from the size of a pea to that of a hazelnut, are 
usually multiple (200 in Snell's case), and contain clear fluid with 
black dots, the heads of the parasites. A fibrous capsule frequently 
develops, and calcification may occur later. The cysticercus race- 
mosus may reach a great size. 

6. Aneurysms. — Aneurysms have been considered under diseases 
of the brain vessels. 

Location. — The location in Gower's figures was: — cerebrum, 42 
per cent.; cerebellum, 25 per cent.; base, 11 per cent.; pons, 8 per 
cent.; central ganglia, 7 per cent.; medulla, 4 per cent.; corp. quad- 
rigemina, 2 per cent. ; cms, 1 per cent. 

Symptoms. — In rare instances, tumor is found at autopsy without 
clinical symptoms (latency). This is due to location of the tumor in a 
"silent" or tolerant brain area; it may occur in tuberculous menin- 
gitis, mental disease, aneurysm, cysticercus, psammoma, cholesteatoma, 
or meningeal tumors, which slowly compress the brain. As a rule, 
symptoms result from the following mechanisms: (a) Direct pressure 
exerted on the brain, which may flatten the convolutions, obliterate 
the sulci, force open the skull fissures in children, absorb or perforate 
the cranium. Pressure is conspicuous in growths of the posterior fossa 
closed by the rigid tentorium. (b) Internal hydrocephalus, distention 
of the ventricles, may follow closure of the aqueduct of Sylvius, or com- 
pression of the veins, particularly of the choroid plexus and the vena 
Galeni magna, and especially by tumors of the cerebellum and corp. 
quadrigemina. (c) The brain may be softened by pressure on its vessels 
(Bouveret), inflamed, or hemorrhage may develop (as in glioma), (d) 
Infiltration or destruction of the brain matter may result, (e) Men in- 



1002 DISEASES OF THE NERVOUS SYSTEM 

gitis, local as in gumma, or general as in tubercle, may develop. (/) 
Auto-intoxication from the growth is possible, as suggested by Klippel. 
(g) Distortion of the cerebral or spinal nerves (Dinkier, Mayer), may 
cause their degeneration, or changes in the posterior columns of the 
cord and its posterior roots. 

The symptoms produced are general (diffuse), and focal (local). 

The general symptoms usually come first in the evolution, and 
include the following: — (a) Headache is present in almost all cases, 
is usually constant, with accessions (especially in the morning), is 
general, rarely unilateral, is severe and obstinate enough to keep the 
patient awake at night, is increased by alcohol, exertion and coughing, 
and rarely corresponds with the tumor's site except when the pain is 
persistently local and the tumor near the surface. (Frontal headache 
often results from tumor in the white substance of the frontal and 
parietal areas, but sometimes may result from tumor anywhere, even 
in the cerebellum, which more often is attended by occipital headache 
or neck-ache.) Headache is usually referred to irritation of the dural 
branches of the fifth nerve, an explanation which is not always satisfac- 
tory. It may be pulsating in aneurysm. (&) Choked disk is the most 
important general symptom, and occurs in 80 to 90 per cent. It consists 
of a grayish-red swelling of the disk, to even two or three times its nor- 
mal dimensions, which lessens its sharpness of outline and physio- 
logical cupping; the arteries become less lustrous and smaller, the 
veins turgid and tortuous, extravasations of blood and white patches 
of fatty degeneration or exudation appear. (See Plate v, fig. 3.). It 
develops in weeks to months, and is due to increased intracranial ten- 
sion, which causes mechanical hydrops of the optic sheath (Schmidt- 
Rimpler, Matz, Sehwalbe),or to inflammation from choking of the veins 
by toxic products (Leber and Gowers). It is bilateral (90 per cent.), 
although more marked on the side of the lesion, is not an early symp- 
tom and depends neither on the size of the tumor nor on its location. 
It is almost always present in growths of the cerebellum and corp. 
quadrigemina, is less frequent in cortical and meningeal localizations, 
and is often absent or appears later in those in the pons, medulla, and 
corp. callosum. There is often, but not always, limitation of the 
field of vision (scotoma for color and lessened acuity of vision). In 
many cases it develops into atrophy, oftener still into stasis and blind- 
ness, while in some it may regress or very rarely recur. Transitory 
amaurosis results from compression of the optic tract or chiasm by 
the distended third ventricle, (c) Convulsions occur in 50 per cent., 
are called the "signal symptoms/' by Seguin, and may be general; 
general tonic precede clonic convulsions in no special order; the pupils 
react poorly, the skin reflexes are increased unless deep coma develops, 
the tendon reflexes are not suspended, respiration is labored and coma 
occurs. Convulsions are more frequently late than early. Slight seizures, 
like the petit mat of epilepsy, may occur. Jacksonian epilepsy belongs 
to the focal symptoms, (d) Vomiting is usually an early general symp- 
tom, indicating irritation of the vomiting centre (it is sometimes a 



BRAIN TUMORS 1003 

focal symptom). It is of the cerebral type, occurring without effort, 
nausea, or pain, often on an empty stomach, as in the morning, or at 
once after eating, regardless of the kind of food ingested; it is initiated 
by sitting up, turning of the head, or excitement. Later the tongue is 
often coated. Vomiting is closely associated with headache and ver- 
tigo, and is due to intracranial pressure or meningeal irritation. It is 
rarely absent in growths of the cerebellum or medulla, is very frequent 
in disease of the corp. quadrigemina, and occurs in 25 per cent, of 
tumors in the hemispheres, (e) The sensor ium is often involved. 
The most common, and sometimes the earliest, change is dulness, 
which often deepens into stupor and coma. It is not surprising that 
tumors affecting the association fibers and avoiding the motor centres, 
may cause disturbance of intelligence, judgment, or memory, only; 
they are frequently discovered at autopsy in the frontal or temporo- 
sphenoidal lobes in subjects committed to asylums, for psychoses or 
general paralysis. Hysteria may occur in subjects of organic brain 
disease. (/) Vertigo is often an early symptom; it may be mere "giddi- 
ness," or it may affect the labyrinth, pons, or cerebellum, and be a 
sense of actual rotation. It is present in 31 per cent. (Mills and Lloyd), 
occurs especially in the locations mentioned and as a focal symptom, 
when the middle cerebellar peduncle is implicated, (g) Slowed pulse 
may result from direct, but more often from indirect, pressure on the 
vagus fibers behind and lateral to the hypoglossal nucleus. The vagus 
fibers become accustomed to pressure of long standing and the heart 
rate increases. It is often associated with yawning, hiccough, Cheyne- 
Stokes breathing, glycosuria, or polyuria. Cardiac disease, chokemia, 
and anaemia must be excluded. 

Focal Symptoms. — Focal symptoms may be absent when the disease 
is limited to "silent," or "tolerant" areas, when the tumor does not 
destroy nerve structures, and when vicarious compensation by other 
parts is possible. Focal symptoms of irritation or paralysis may result 
directly from actual lesion of a centre or its fibers, or indirectly from 
"distance pressure" upon them. (They are, therefore, most signif- 
icant when no particular increase of intracranial tension exists.) 

1. Frontal Lobes. — The reported changes in mentality are much 
discussed; early observers, as Bernhardt, claimed that mental changes 
were no more frequent in frontal localization than in localization else- 
where. Many cases show the symptoms indicated above. Jastrowitz 
describes a condition designated as moria, a dementia with character- 
istic irritability and excitement. A tendency to make jokes (Witzel- 
sucht) is described by Oppenheim. Psychical changes, especially 
those developing early, justify a "probability" diagnosis only. Allan 
Starr records the first case in which diagnosis was confirmed by opera- 
tion. "The two prominent characteristics of the mental state are 
apathy and suffering, which may be associated or alternate" (Church ). 
Early or late mental alteration sometimes follows other localization-. 
Sometimes tumors in the frontal lobes are thought to be in the motor 
areas from indirect pressure upon the latter. The head and eyes may 



1004 DISEASES OF THE NERVOUS SYSTEM 

deviate, and the neck and back are sometimes rigid. Bruns has re- 
corded frontal tumors with cerebellar ataxia, which is caused by 
unequal innervation with disturbance of the sensorium (Oppenheim), 
or involvement of the trunk centres (St rump ell). Some would asso- 
ciate with frontal lesions a lack of initiative. The motor centres in the 
left lower frontal convolution may be directly or indirectly involved. 
Bradyphasia (slow speech) is probably psychical, and differs from the 
separation of syllables sometimes seen in tumor of the pons. Oppen- 
heim speaks of "laryngeal aphasia," in which the patient moves his 
lips and attempts to speak, but finds the voice lacking. 

2. Motor Cortex. — (a) Jacksonian convulsions are often (50 per 
cent.) dissociated, and follow a given sequence (see Cortex Localiza- 
tion); consciousness is often preserved unless the other side of the 
body is involved. The convulsions may be few, with long intervals, 
or may run into the hundreds (17,000 in eleven months, as reported by 
Gowers). They may be preceded by the general convulsions described 
above. When the conducting fibers are destroyed, they cannot occur, 
whence they may be observed in the part nearest the seat of greatest 
damage. As long as convulsions are present, the motor centres cannot 
be wholly destroyed. Tapping the tendons or the skull may initiate 
spasms, and it has long been recognized that convulsions can sometimes 
be aborted by electricity, by grasping the arm, etc. (b) Cortical paralysis 
or paresis is usually monoplegic, and is associated with cortical spasm. 
It is usually slight at first, for a weakness from exhaustion follows the 
spasms; later it becomes more marked. In some cases paresis (or total 
hemiplegia) may be the first sign of tumor, and sometimes may be most 
narrowly localized, as in the thumb alone, the four fingers, or great 
toe; paralysis is accompanied by increased reflexes, rigidity, and rarely 
by muscular atrophy. Surgical extirpation has relieved both spasms 
and paralysis. In infrequent cases the paralysis may be bilateral, as 
when a cortical tumor near the median line presses on the opposite 
hemisphere, or when there are bilateral symmetrical growths; these, 
however, are still rarer, (c) Sensory changes are less frequent, because 
the sensory area is larger than the motor area, and extends posterior 
to it, and it is possible that sensory representation is bilateral. (The 
gyrus fornicatus is thought by some writers to be the seat of tactile and 
muscular sensibility.) Hypsesthesia, especially for tactile and mus- 
cular sensibility and paresthesia, are not rare. Cortical pains are rare. 
Vasomotor symptoms, tachycardia, and salivation (also in tumors of 
the frontal lobe), are observed, but are not localizing signs. 

3. Parietal Lobes. — Some sensory disturbance is fairly common. 
Incoordinate movements, ataxia, and athetosis have been observed. 
Wernicke observed a tumor in the lower parietal lobe with conjugate 
eye movements, and Weil noted incoordination of the extremities on 
the opposite, and of the eyes on the same side of the body. Sensory 
aphasia, hemianopsia, deafness, and word deafness are also observed. 

4. Temporal Lobes. — Symptoms are likely to be confused with those 
of the contiguous occipital lobes; hemianopsia, disturbance of eye 



BRAIX TUMORS 1005 

movements, chiefly toward the opposite side, ptosis, and agraphia are 
recorded. 

5. Occipital Lobes. — Hemianopsia is the most constant finding; 
it results from any occipital lesion large enough to compress the optic- 
radiation in the white substance (Henschen). Optical hallucinations 
are thought to indicate a cortical occipital localization rather than one 
in the optic radiation. Alexia, optic aphasia, and psychical blindness 
are seen. 

6. Pons. — Focal may precede the general symptoms; they have 
been enumerated under cerebral localization. Hemiplegia with alter- 
nating paralysis of some of the first eight cranial nerves is the most 
common type (in 50 per cent.). The fifth nerve may be involved in 
its sensory or motor branches. Foci in the substance of the pons involv- 
ing the sixth nerve usually also involve the third nerve of the opposite 
side; foci near the surface involving the sixth nerve do not involve the 
third nerve. Sometimes the nerves may be involved without hemi- 
plegia (25 per cent.), but rarely without crossed motor irritation or 
hemiansesthesia ; hemiplegia alone occurs in 25 per cent. Unilateral 
tumor of the pons may also compress the opposite motor tracts (para- 
plegia or diplegia) and cranial nerves. Motor irritation is not uncom- 
mon, as trismus, facial spasm (Kolish), and sometimes trigeminal 
neuralgia, convulsions in the contralateral limbs, etc. Tetanic rigidity 
is rare. Sensory disturbance is usual, as a result of involvement of the 
lemniscus and formatio reticularis, and occurs as hemiansesthesia 
cruciata (in arm and leg of one side, and in the face of the opposite 
side when the focus is low in the pons), hemiansesthesia of face, arm, 
and leg of the same side (tumor in the upper pons), and anaesthesia of 
one or perhaps of both sides. Dysarthria, dysphagia, difficult urination 
or defecation and disturbed respiration on change of posture (Pichler) 
have been observed. 

7. Medulla. — It is remarkable that not only cystic but also solid 
tumors may produce no symptoms or only such that localization in 
the pons or cord is first suggested. In a small number of cases only 
are the symptoms not ambiguous. Bilateral paralysis of the ninth 
to twelfth nerves with degeneration and atrophy of the lips, tongue, 
palate, pharynx, or larynx, is characteristic, and presents a picture like 
progressive bulbar palsy. Alternating hemiplegia is rare, but has been 
observed in cases of gliosis. Sensory, motor, atactic, and nerve involve- 
ments are usually bilateral. Growths outside the medulla may cause 
paralysis of the neck muscles (spinal accessory nerve). Slowed or 
rapid pulse, singultus, embarrassed breathing, glycosuria, and polyuria 
are not uncommon. Laslett recently described degeneration in the 
posterior columns of the cord from pulling of the medulla on the pos- 
terior cervical roots, or from toxaemia, which was previously found 
by Batten and Collier (1889.) 

8. Cerebellum. — Cerebellar ataxia, referred by Nothnagel and 
Gowers to lesions of the vermis in 80 to 90 per cent, of the cases, occurs 
but half as frequently in disease of the cerebellar hemispheres. 



1006 DISEASES OF THE XERYOUS SYSTEM 

Compression of the pons, medulla, corpora quadrigemina, and fifth to 
twelfth cranial nerves is somewhat characteristic. Sachs regards 
involvement of the sixth nerve as almost pathognomonic. Of the 
general symptoms, choked disk is severe and almost invariable; occi- 
pital headache and rigid neck are very frequent. Convulsions are 
common, and opisthotonos with tetanic rigidity of the body and 
extremities is most suggestive. 

9. Optic Thalamus. — In most cases spastic hemiplegia results from 
invasion of the internal capsule; hemichorea, hemiathetosis, hemi- 
anaesthesia and Nothnagers mimetic paralysis are not infrequent. 
Less common are unilateral convulsions, forced movements or pos- 
tures, contralateral hemianopsia, paralysis of the eye muscles, widen- 
ing of the opposite pupil and monoplegia. 

10. Corpus Callosum. — Bristowe and others believe that the follow- 
ing symptoms are characteristic; dementia (in 90 per cent.), absence 
of initiative in speech and action, paraplegia, dysarthria and but slight 
general symptoms, as choked disk. Oppenheim holds that there are 
no distinctive symptoms. 

11. Corp. Quadrigemina. — Ocular paralyses (of the third nerve) 
are common, and are sometimes associated as double ptosis, and bilat- 
eral paralysis of the internal recti. The pupils are usually free but 
may be unequal. Oculomotor paralysis may exist with crossed hemi- 
ataxia from involvement of the tegmentum, or pressure on the cere- 
bellum. Disturbed hearing from destruction of the upper layer of 
the tegmentum, amblyopia, and intention tremor, are also observed. 
No paralysis, except of the third nerve, is present, unless the tumor 
extends beyond the corp. quadrig. (Oppenheim). 

12. Pineal Gland. — The symptoms are the same as when the corp. 
quadrigemina are affected, save that the fourth and sixth nerves are 
involved more than the third, and compression of the pons or medulla 
is more common. 

13. Tumors at the Base.— These include bone tumors, aneurysms, 
hypophysis growths, and those from the nerves or meninges, (a) At 
the anterior fossa, hypophysis tumors (see Acromegaly) disturb vision, 
and produce bitemporal hemianopsia with amblyopia or sometimes 
irregular or transverse hemianopsia. In some instances, there is am- 
blyopia of one eye and hemianopsia of the other. Usually there is no 
choked disk, but simple optic atrophy is present. The third nerve is 
paralyzed in most cases, and sometimes other ocular trunks are also 
affected. Exophthalmos is occasional and the growth may perforate 
externally into the eye, pharynx, or nose. Loss of smell (anosmia), and 
mental symptoms are also observed in tumors of the anterior fossa. 
(6) When they occur in the middle fossa, mental symptoms and con- 
vulsions are less common. The Gasserian ganglion may be compressed 
and result in neuroparalytic ophthalmia. Other cerebral nerves, as 
the third, and sixth, sometimes suffer. It must be recalled that a tumor 
elsewhere may indirectly compress the basal structures. Syphilis and 
sarcomatosis may be diffusely basal, (c) Lesions in the posterior fossa 



BRAIX TUMORS 



1007 



may simulate bulbar palsy. The lower eight cranial nerves may be 
affected and usually suffer more readily and earlier than do the pyra- 
midal tracts; the grouping of the cranial nerve implication is different; 
thus paralysis of the sixth nerve is rarely associated with the conjugate 
fourth nerve, as occurs when the lesion is central. The seventh and 
eighth nerves are often conjointly paralyzed in disease of the posterior 
fossa, and but rarely so in central tumors. The symptoms often re- 
semble those of lesions of the pons, medulla, or cerebellum. 

Diagnosis. — Diagnosis depends upon the combination of focal and 
general symptoms. Four general groups of cases are encountered: — 
(1) Absolute clinical latency; (2) general and focal symptoms, the 
typical case; (3) general but no focal symptoms; (4) definite symptoms 
of some brain disease but of equivocal significance. According to 
Brims, 80 per cent, of cases can be detected. 

Analysis of the General Symptoms. — (a) Headache is suggestive 
when it is severe, keeps the patient awake, and when the skull is tender 
to percussion or pressure (the parietal regions are normally somewhat 
sensitive). Its associates, as choked disk or vomiting, are equally 
important. Organic irritative brain disease, as abscess or inflamma- 
tion, may cause headache, but mere increase of intracranial tension, 
as in hydrocephalus, need not do so. Functional nervous disease may 
cause headache, as migraine, neurasthenia, hypochondriasis, hysteria; 
it may result from eye disease, morbid conditions of the blood or intoxi- 
cations (ursemia, gastro-intestinal disorder, and poisoning by nicotine, 
opium, alcohol, or lead), and from arteriosclerosis. (b) Choked disk 
in 80 or 90 per cent, of cases indicates brain tumor (Oppenheim), and 
if very marked, it is seldom due to other causes. It is less frequent in 
abscess and meningitis, in which neuritis optica is more frequent. It 
is most rare in embolism, softening, hemorrhage, hematoma durse 
matris, arteriosclerosis, poliencephalitis, encephalitis, the acute fevers, 
lead poisoning, neuritis multiplex or alcoholism (in which central 
scotoma is present). Uraemia must be excluded; although the two 
diseases have much in common, as headache, epileptiform or apoplecti- 
form attacks, hemiplegia, aphasia, and slow pulse, neuroretinitis is 
more common in nephritis, though local causes back of the orbit may 
sometimes produce it. The choked disk of chlorosis is rare, but 
responds readily to rest and treatment by iron. Optic atrophy has the 
same significance as choked disk, (c) General epileptiform convul- 
sions occur in meningitis, pachymeningitis, abscess, vascular disease, 
syphilis, alcoholism, plumbism, multiple sclerosis, paretic dementia, 
ursemia, and gastro-intestinal disease in children. 



Epileptic Convulsions. 

More coarse; more biting of tongue; 
more frequent cry; more sudden, and 
complete loss of consciousness, fre- 
quently a visceral (epigastric) aura; 
usually longer interval between 
attacks. 



Convulsions Resulting from 
Organic Brain Disease. 



Convulsions more orderly, slow, clonic, 
broken by tonic contractions: often 
with gradual local commencement, 
without loss of consciousness, and 
with paresis in the Jaeksonian type. 



1008 DISEASES OF THE XERYOUS SYSTEM 

(d) Vomiting is probably cerebral and organic, and due to tumor, 
if hysteria, migraine, anaemia, toxaemia, and gastric disease can be 
excluded. It occurs on getting up in the morning, and is often asso- 
ciated with vertigo, syncope, and irritability of the nervous centres. 

Combination of General Symptoms. — Headache and choked disk 
occur in chlorosis (v. s.), in plumbism (also with delirium, convulsions, 
and coma, but distinguished by the lead line on the gums), or in uraemia 
in which special examination for albumin, casts and cardiovascular 
changes are definitive. The same combination may also prevail in 
hypermetropia in anaemic girls, in amenorrhoea (Broadbent), and in 
injuries of the head, but care usually distinguishes them from brain 
tumor, which is characterized by its slow onset and usual focal signs. 

Focal Symptoms and Topical Diagnosis. — Focal symptoms usually 
follow the general, whereas, in apoplexy, for example, the focal 
symptoms, as hemiplegia, are early. In tumor with hemiplegia, con- 
tracture or spasticity accompanies the paralysis rather than follows it, 
as usually occurs in hemorrhage or embolism. Hemiplegia from a 
tumor is less pure, less circumscribed, less systematic (Fournier). A 
tumor at the base may cause hemiplegia, not from direct involvement of 
the internal capsule or pons, but from pressure on the middle cerebral 
artery with encephalomalacia. Jacksonian epilepsy with paresis is, 
in 50 per cent, of cases, due to cortical tumors. It is also produced by 
hemorrhage, softening and inflammation, and is then earlier, is not 
confined to as small an area, and is not as progressive as in neoplasm. 
The cortical paralysis and epilepsy observed in alcoholism, paretic 
dementia, plumbism, uraemia, and rarely in tuberculosis, cancer, and 
diabetes (Senator), are not dissociated and are but transitory. 

Nature of the Growth. — (a) This may be determined in part from 
its location. Cortical growths are most probably gumma or tubercu- 
losis (possibly glioma, cysts, cysticercus, or sarcoma); subcortical, 
glioma, or sarcoma; pons, tubercle, gumma, glioma; cerebellum, tu- 
bercle or glioma ; extracerebral, sarcoma ; multiple occurrence, tubercles 
or gummata. (b) Its nature may also be determined from its course. 
A rapidly growing tumor is most probably glioma or sarcoma. An 
apopleptic attack indicates glioma or ruptured aneurysm. Growth 
with remissions is characteristic of tubercle or glioma. A very slow 
course suggests fibroma or osteoma. Coincident meningitis indicates 
tubercle or syphilis. 

Differentiation. — Tumors must be distinguished from brain abscess; 
abscess and tumor have much in common, as their general symptoms; 
both may result from trauma, but brain abscess is almost always sec- 
ondary to trauma, or to a pus focus (otitic or metastatic) ; unilateral 
optic neuritis is a much more common symptom than choked disk, 
and abscess (q. v.) when once "manifest" is more apt to produce fever, 
chills, a rapid course and apopleptic seizures than is tumor, while 
involvement of the cranial nerves is less frequent. It must be borne in 
mind that bulbar tumors may cause fever, and that in abscess, for a 
time at least, there is a normal or subnormal temperature. Differenti- 



BRAIN TUMORS 1009 

ation from paretic dementia, pachymeningitis hemorrhagica interna, 
meningitis, syphilis, and hydrocephalus, will be considered under each 
disease. 

Chronic meningitis (syphilitic, tuberculous or actinomycotic) or 
meningoencephalitis may be confused with diffuse tumors at the base, 
but lack pressure symptoms and progression. 

Multiple sclerosis must be differentiated. In both affections inten- 
tion tremor, disturbance of speech, mental change, vertigo, nystag- 
mus, apoplectiform or epileptiform attacks and tonic spasms of the 
extremities may occur, but marked brain symptoms rather speak 
against multiple sclerosis at least in its earlier stages. The pressure 
symptoms of tumor and increase of cerebrospinal fluid are absent 
and in the disk there is an incomplete optic atrophy. If undue stress 
be placed on the tremor, it may be confused with the incoordination 
tremor of tumor in the optic thalamus, pons or cerebellum. 

Course and Prognosis. — The first symptoms are usually general, 
followed by the focal symptoms. If left to itself, the disease runs a 
fatal course in one-half to two years, although in rare cases it endures 
four to fourteen years. A long latent tumor may appear to begin 
acutely. Exacerbations result from aneurysmal rupture, hemorrhage 
into a glioma, cyst formation, ventricular effusions, meningitis, or local 
neuritis. Remissions are not uncommon; healing of parasitic and 
simple cysts, aneurysms, tubercles (in the young) and gummata is 
possible. It was thought that aneurysms and gliomata may be cured 
with iodide treatment (Wernicke). Unfavorable symptoms are pro- 
nounced mental change, incoercible vomiting, irregular and rapid 
pulse, repeated fits, apoplectiform seizures or festinating neuritis optica. 
The mechanism of death is (a) exhaustion from vomiting, pain, or 
cachexia; (6) inhalation pneumonia; (c) coma with disturbed respira- 
tion, circulation, or other bulbar signs; (d) sudden death in tumors of 
the base (rarely of the cortex) ; (e) meningitis or arterial disease ; (/) 
intercurrent infections. 

Treatment. — Medical treatment does not produce encouraging 
results, save in cases of syphilis, but every patient should be given a 
course of mercury and iodide for at least three months. Tubercle may 
sometimes be arrested by increasing the physiological resistance by 
forced feeding, fresh air, and administration of cod-liver oil and arsenic. 
The headache is often relieved by iodide, in any kind of tumor, by the 
ice-bag, morphine, atropine, hyoscine, the coal tar products, and by 
trephining. Convulsions should be treated by chloral. Brain con- 
gestion resulting from alcoholism, excitement, exertion, overeating, or 
obstipation should be avoided. 

Surgical Interference. — Macewen, Horsley, Bennett, Ferrier, and 
Godlee are the pioneers in brain surgery, (a) In radical operation 
the outlook is not very encouraging. Allan Starr estimates that but IS 
per cent, of tumors are accessible, and but 7 per cent, removable; 
Siedel finds only 3 per cent, are operable. Thirty-four per cent, is 
basal. At operation the tumor is found in 64 per cent, of cases. The 

64 



1010 DISEASES OF THE XERVOUS SYSTEM 

best results are obtained in meningeal and the next best in cortical 
growths, especially of the motor and occipital zones. Duret (1903) 
analyzed 344 operations; 18 per cent, died, 64 per cent, improved and 
vision was completely restored in 60 per cent., and partially in 18 per 
cent. In cerebellar tumors, sudden death is frequent, because of 
manipulation compression of the medulla. In 116 operations for 
cerebellar growth, the mortality, once 70 per cent., is now 38 per cent. 
(Frazier, 1905). 

All varieties, even the syphilitic scar or tubercle, may be removed, 
excepting metastatic growths. Recovery from the operation is fre- 
quent, although the mortality ranges from 20 to 50, or even 80 per 
cent. But few ultimately recover. Recurrence is common. Death 
occurs from hemorrhage, sepsis, dislocation of the brain, basal com- 
pression, brain oedema and shock. Horsley and Macewen have sug- 
gested that the operation be performed in two steps; first exposing 
the tumor, and later removing it, after the brain has accommodated 
itself to the change of relations, (b) Palliative operation may be bene- 
ficial. Removal of a button of bone with incision of the dura often 
greatly relieves the headache and growing blindness, allows fluid to 
escape and permits the tumor to grow outward when it cannot be 
removed. Henschen claims that the palliative procedure hastens 
death more than twice as frequently as it relieves the symptoms, (c) 
Ventricular drainage has not proven helpful and lumbar puncture is 
dangerous; 17 cases of sudden death are reported to have resulted 
from it. 



(D). INFLAMMATION OF THE BRAIN. 
I. Encephalitis. 

Acute encephalitis is not "inflammation of the brain" (as under- 
stood by the laity), which is meningitis. Encephalitis does not include 
the zone of inflammation wmich occurs about tumors, foci of hemor- 
rhage, softening, syphilis, and meningitis. It was once held by Durand- 
Fardel that all softening was encephalitis (cerebritis). Gluge (1837) 
suggested that some cases were encephalomalacia; Coswell and Hasse 
(1850) definitely distinguished between them; and Virchow anatom- 
ically and Hayem clinically, followed by v. Leyden, Erb, Westphal, 
Foville, and Otto, described definite cases. The work of Wernicke, 
Striimpell, Leichtenstern, and Oppenheim will be mentioned later. 

Etiology. — There are three main etiological factors; they are (a) 
intoxications, chiefly from alcohol, and far less often poisoning by sul- 
phuric acid, ptomaines in decayed meat and fish, nicotine, and sun- 
stroke, (b) Infections, especially influenza, then scarlatina, measles, 
hydrophobia, ulcerative endocarditis, and numerous other infections. 
In such cases, microbes may invade the brain alone. Some relation 
to chlorosis, sinus thrombosis, chorea insaniens or maniacal forms of 



ENCEPHALITIS 1011 

exophthalmic goitre is possible, (c) Trauma, by laceration or concus- 
sion, directly or indirectly may produce a locus resistentim minor is 
for secondary microbic invasion, although an aseptic form is said to 
exist. 

Pathology. — Wherever located (v. i.), the process begins as mul- 
tiple disseminated and often symmetrical foci, principally in the gray 
matter; these grow and diffuse, sometimes most widely. They vary 
in size from microscopic dots to a diameter of several inches, but usually 
are the small "flea bite" areas of capillary hemorrhage, which 
glisten and stain the adjacent tissues, show above the cut section and 
later become foci of softening. Microscopically, hyperemia, perivas- 
cular exudation of red and white cells, serous effusion and changes 
in the nervous elements are observed. Aggregations of mononuclear 
cells are seen, somewhat resembling a tubercle, which Popoff claims 
may actually enter the ganglion cells, which become degenerated, fatty, 
and swollen; the medullary sheaths and later the axis cylinders de- 
generate. Its issues are: — (a) regression (recovery); (6) necrobiosis 
with softening; (c) cyst formation; (d) cicatrix formation with enclos- 
ure of fatty granules or hsematoidin, or (e) it may possibly spread as 
diffuse brain sclerosis or (/) may become the foci of multiple sclerosis. 
Associated nervous changes are optic neuritis, multiple neuritis, and 
poliomyelitis, and general changes are enlarged spleen, retinal or general 
hemorrhages and parenchymatous degeneration in the kidney, etc. 

Special Pathology and Symptomatology. — 1. Poliencephalitis Acuta 
Superior Hemorrhagica (or Ophthalmoplegia) . — This was said by 
Wernicke (1881), and also by Badeker, to occur in alcoholic sub- 
jects, and therefore in adults; it attacks the gray matter about the 
third and fourth ventricles, and aqueduct of Sylvius, whence it may 
spread upward or downward; it results in eye paralysis, and is anal- 
ogous to acute poliomyelitis. The general symptoms are delirium 
tremens, or somnolence in non-alcoholics, headache, vomiting, and 
rigid neck. The local symptoms consist of an early extensive ophthal- 
moplegia, which involves associated eye muscles, as the two internal 
recti, or the internal rectus of one eye, and the external of the other, 
and usually leaves the pupil and the levator palpebral superior free. 
The gait is almost invariably atactic and unsteady from involvement 
of the corpora quadrigemina. Speech is frequently difficult. Neu- 
ritis is observed in the optic disk, and sometimes in the peripheral 
nerves, as evidenced by the absent patellars, ataxia, tender muscles, etc. 
Sometimes there is hemiparesis and facial paresis. The temperature 
is usually normal, or in alcoholics may be subnormal, though respira- 
tion and pulse are increased. Death occurs within two weeks after 
these violent symptoms. This type is most easily recognized, although 
syphilis, tumors, or encephalomalacia may affect the same nuclei. 
Some cases thought to be nuclear have been shown by B a decker, 
Thompson, and Jacobseus to be polyneuritic, and others have shown 
no pathological alteration at autopsy. The diagnosis is easiest in this 
type. 



1012 DISEASES OF THE NERVOUS SYSTEM 

2. Encephalitis (or Porencephalitis) Hemorrhagica. — Striimpell 
(1884) described primary cases of infantile paralysis (q. v.) in which 
he referred the lesion to inflammation of the motor cortex; though his 
theory in explaining all such cases is too general, some anatomical 
confirmation of it is not lacking (Ganghofner). In 1885-86, Leich- 
ten stern saw cases which resulted from the infections named under 
etiology. Foci are found in the cortex, subcortex, or central ganglia, 
containing pus cocci, and influenza bacilli. In some cases the autopsy 
showed nothing, and intoxication was then assumed. The disease 
occurs mostly between the fifteenth and thirtieth years, but also in 
children. After an influenza, there may be (a) general symptoms, as 
headache, vomiting, delirium, mental obscuration, convulsions (in the 
young), high fever without chill, slowed pulse becoming rapid, and 
irregular breathing, or sometimes stiff neck or optic neuritis; (b) focal 
symptoms appear after a few days, as hemi- or monoplegia, aphasia, 
conjugate deviation, focal convulsions, or hemichorea (Friedmann). 
The reflexes are affected as in apoplexy. The course lasts one-half to 
three weeks, and is often fatal, but recovery is not rare. This form 
may resemble hemorrhage, syphilis or softening, but occurs in the 
young with normal arteries, and the paralysis is preceded by signs of 
infection, fever, enlarged spleen, somnolence or convulsions. Sinus 
thrombosis cannot be differentiated but meningitis is usually differ- 
entiated with ease. 

3. Subtypes. — These consist of the following: (a) poliencephalitis 
inferior acuta, involving the pons or medulla, and giving acute bulbar 
symptoms; there is paralysis of the sixth, seventh, to twelfth nerves 
when it occurs in various combinations, or with types (1) and (2). 
Some of the cases (chorea insaniens, Basedow 's disease with mania), 
may show nothing at autopsy, whence the diagnosis is very uncertain. 
Confusion with softening, hemorrhage, the late hemorrhage of trauma, 
or tumors is possible, (b) Another form is poliencephalomyelitis , acute 
(Kaiser), subacute (Kalisher), or chronic (Rosenthal), in which the 
type of Wernicke or of Strumpell-Leichtenstern may descend and 
co-exist with inflammation and paralysis, frequently symmetrical, 
of the anterior spinal roots. Hutchinson 's facies is observed, viz., 
fixed eyes, fallen lids, prominent eyebrows, obliterated nasolabial 
folds, and atrophic paralysis of the arms. Differentiation from mul- 
tiple neuritis is usually possible, and Oppenheim's criteria are well- 
established in its separation from myasthenia gravis, in which there 
is (i) no atrophy, but (ii) remissions in the paralysis, (iii) great mus- 
cular adynamia, (iv) absence of reaction of degeneration, and (v) nega- 
tive anatomical findings. 

Prognosis. — The prognosis is unfavorable, as a rule. The peracute 
cases may die in two days; acute cases last one-half to three weeks, 
and death is most frequent; Oppenheim has shown that they may 
recover. Much involvement of the mind, decubitus, alcoholic delirium, 
chlorosis, sinus thrombosis, and weak pulse are unfavorable elements. 
In children recovery is common, but epilepsy, paralysis, mental altera- 



ABSCESS OF THE BRAIX 1013 

tion and possibly multiple sclerosis are sequences. Even the bulbar 
type may recover. 

Treatment. — This is wholly symptomatic, (a) The causal feature 
must be eliminated, (6) cerebral congestion avoided, and (c) the skin, 
bowels, and bladder, the delirium and convulsions, the diet, and the 
patient 's rest must be cared for as in brain hemorrhage, softening, or 
tumor, (d) Mercurial inunctions, iodoform inunctions and potassium 
iodide give the best results, (e) Electricity is indicated in the chronic- 
stage. 



II. Abscess of the Brain. 

Brain abscess (encephalitis suppurativa or apostematosa) is not a 
common disease. Eichhorst found but three among 13,563 medical 
cases. 

General Etiology. — All cases are caused by microorganisms, of 
which the streptococcus is the most frequent, the staphylococcus com- 
ing next and then the pneumococcus, and other bacteria. Mixed infec- 
tions are common, and old abscesses are often sterile. Sixty-six to 75 
per cent, occurs in men. It is most frequent between the twelfth and 
thirtieth year. Twenty per cent, occurs in the second, and 33 per cent, 
in the third decade (Gowers). The cerebrum is involved in about 75 
per cent., and the cerebellum in 25 per cent., but the pons and medulla 
are rarely involved. 

General Pathology. — The focus is single in 80 per cent, of cases. 
The average size is from one to two inches, but may be almost micro- 
scopic or may occupy nearly the entire hemisphere. The surrounding 
brain may be inflamed. Durand-Fardel described the various plaques 
mentioned under embolism as various stages of inflammation. It is 
possible that the red softening may sometimes be the first stage of 
inflammation, although far more often due to ischsemia. A zone of 
oedema is common. The right side of the brain is more often affected 
than the left. Pressure is less common and less intense than in tumor, 
though large abscesses flatten the brain and may produce internal 
hydrocephalus. The abscess consists of pus of variable consistency, 
yellow or green, acid, sometimes rancid, foetid or putrid; flocculi of 
disorganized brain tissue are common. The pus cells are often indis- 
tinct and fatty needles, cholestearin crystals and sometimes corpora 
amylacea or foreign bodies are found. Putridity is due to communica- 
tion with the nose or ear, or embolism from putrid lung foci. Encap- 
sulation occurs in 50 per cent., chiefly in old, slow cases, and requires 
from two weeks to two months. The capsule rarely completely or 
permanently limits the abscess which usually grows and often rup- 
tures, although ultimate quiescence from inspissation and successful 
demarkation is barely possible. 

Special Etiology and Pathology.— 1. Foci near the brain are its 
usual causes, and for this reason brain abscess is seen by internalists , 



1014 DISEASES OF THE NERVOUS SYSTEM 

neurologists, surgeons and otiatrists. (a) Ear disease explains at least 25 
per cent, of brain abscess (even 33 or 42 per cent.). Otitis media is the 
most frequent cause and is chronic in 91 per cent. (Griinert). Insur- 
ance companies generally recognize the risk in these cases. Jansen 
found one abscess to 500 cases of chronic, and one to 2,650 of acute, 
otitis. The ear disease may date back thirty or forty-five years, and 
is especially dangerous when it recurs and when granulations and 
polypi exist. The acute infections are thus indirectly causative of 
brain abscess. Infection traverses the bone (92 per cent., Korner), 
to the dura by way of the thin tegmentum tympani, by the roof of the 
antrum, sometimes through the petrosquamous suture (in children), 
by the mastoid cells, lateral sinus, labyrinth or aqueduct along the 
sheaths of the seventh and eighth nerves (though this is more common 
in meningitis), and rarely by the external canal. Korner 's figures 
show that in 42 per cent, there is a fistule between the abscess and the 
causal focus; in 15 per cent, the dura interposes between the two foci; 
in 15 per cent, there are dural adhesions, and in 17 per cent, the inter- 
vening substance is softened brain tissue. Toynbee (1885) remarked 
that (i) disease of the roof caused temporosphenoidal abscess, but 
(ii) disease of the mastoid cells chiefly produced cerebellar abscess. 
Of otitic abscess, temporosphenoidal constitutes 67 per cent. (75 per 
cent, in children under ten years), and cerebellar abscess 33 per cent. 
(Korner) ; the latter is most rarely due to any other cause than otitis, 
and almost invariably occurs in the anterior part of its hemispheres. 
Otitic abscess infrequently involves the occipital, frontal (two personal 
observations) or parietal lobes. The abscess is single (87 per cent.), 
and lies in the white substance of the brain just beneath the cortex. 
The smaller the abscess, the nearer it lies to the cortex. Cholestea- 
tomata (pearly tumors) may cause some cases. (b) Traumatism 
produces 25 per cent, of the cases. Punctured wounds are more danger- 
ous than open compound fractures. Fractures of the base may result 
in abscess by infecting the middle ear. Splintering of the inner table, 
and operations on the brain are possible causes; abscess may occur 
without skull fracture, for contused areas may be infected through the 
blood. The injury may be direct, or in rare cases, on the opposite side 
by contre coup. Gowers states that but 20 per cent, occurs under ten 
years of age. Ninety-three per cent, are solitary abscesses (Oppenheim). 
Infection travels along the perivascular (and perineural) lymph sheaths 
(Biswanger), but may pass by other routes (arterial thrombosis, or 
by way of the diploe veins, with or without thrombosis, for "retro- 
grade infection" is possible by the valveless veins). The early trau- 
matic abscess is usually cortical; the late variety is usually subcortical. 
(c) Other contiguous disease is much rarer, causing but 3.5 per cent, of 
brain abscess. Disease of the nose and communicating sinuses (frontal, 
antral, sphenoidal, ethmoidal), may cause abscess of the frontal lobes 
near the diseased bone, and in antrum disease, sometimes of the 
parietal lobes. Disease of the orbit, as phlegmon, or penetrating 
wounds, and still more rarely cervical cellulitis, cranial osteomyelitis, 



ABSCESS OF THE BRAIX 1015 

ulcerative tuberculosis, syphilis or tumor of the cranial bones, may 
cause abscess by contiguity. 

2. Distant foci, or metastatic abscesses cause 25 per cent, of brain 
abscess. The abscesses may number from 2 to over 100 (v. Berg- 
mann); they are multiple in 50 to 75 per cent. In location they are 
cortical or subcortical, less frequently they occur in the central ganglia, 
rarely in the cerebellum, and almost never in this location alone. The 
embolus is almost never found, (a) Lung lesions: "pulmonal cerebral 
abscesses" are due to empyema, putrid bronchitis, and bronchiectasis 
(45 per cent. Williamson), gangrene, abscess, and sometimes tubercu- 
lous cavities. This form rarely encapsulates, (b) Ulcerative endocar- 
ditis, pyaemia, osteomyelitis, etc., are less common causes; paradoxical 
embolism may occur through an open foramen ovale, whereby the 
clot escapes the lungs. Actinomycosis, suppurating tubercle (D'Es- 
pine, Frankel), and oidium albicans (Zenker and Ribbert) have been 
described; in thrush Wagner directly traced the growth from the 
throat to the brain. 

3. The existence of idiopathic brain abscess is denied by some, but 
Gowers found it in 16 per cent, of his cases; it may possibly result from 
a forgotten trauma or ear abscess. Martius and Strumpell believe the 
meningococcus causes some cases of this class. 

Symptomatology. — Symptoms are absent in 5 to 10 per cent, of 
cases. In 17 cases of Martius' series, brain abscess was not diagnos- 
ticated. Symptoms of the causal affection, trauma, otitis, or metas- 
tasis are described under diagnosis. 

1 . Symptoms of Sepsis. — (a) Fever is frequent. Oppenheim considers 
it the most important general symptom; Eichhorst describes cases 
closely resembling typhoid; it is present in acute cases, and in many 
during the last stages when the abscess spreads or meningitis or sinus 
thrombosis develops; the original disease may cause it. Macewen's 
cases showed normal or subnormal temperature. Though it is probably 
overlooked in some cases, it is again totally absent in others, (b) Chills 
are not frequent, (c) The pulse is often accelerated, but may later 
become slowed to 30 or 40, the compression pulse, (d) There may be 
other septic signs, as gastric disturbance, anaemia, emaciation, pepton- 
uria, or leukocytosis. 

2. General (Diffuse) Brain Symptoms. — These are due to compres- 
sion, oedema, inflammation, meningitis, or internal hydrocephalus, and 
include (a) headache, which is most common, and usually severe, 
though less so than in brain tumor; it is due to increased intracranial 
tension; it is usually localized, but even then, the stiff, painful neck 
and headache are general rather than focal symptoms. It is frequently 
associated with (b) vomiting, and (c) vertigo, which also occurs in simple 
ear disease, (d) Mental symptoms are like those of tumor, "slow cere- 
bration, heavy comprehension, and a want of sustained attention" 
(Macewen). (e) General convulsions are frequent only in the last 
stages, in cases of extensive abscess or rupture into the ventricle. (/) 
The pulse is often slowed, even with co-existent fever, to 40 (even 16 or 



1016 DISEASES OF THE XERVOUS SYSTEM 

10), and sometimes with slow or irregular respiration, (g) Optic neu- 
ritis is more common than choked disk; it occurs in 33 to 40 per cent., 
develops rapidly, and may produce amaurosis and atrophy. 

3. Focalizing symptoms are often absent, and when present, are less 
conspicuous than in tumor, because they are obscured by the primary 
a flection or the general symptoms and occur in areas of less physio- 
logical dignity. When present, they usually signalize advance of the 
abscess, increase of surrounding oedema, softening or increased brain 
tension. 

Frontal or mental symptoms may occur (see Tumor), but foci as 
large as the fist may remain latent. They may impinge on the motor 
cortex. The symptoms are those of a cortical lesion (dissociated 
paralysis), which extends more rapidly than tumor, and is attended 
bv Jacksonian fits, rioiditv and increased tendon and decreased skin 
reflexes on the contralateral side; in subcortical lesions from traumatic 
and metastatic (pulmonal) abscess, hemiparesis occurs in 50 per 
cent., is sometimes progressive, is usually incomplete and at times is 
apoplectiform in onset (three personal observations), even when not 
embolic. If hemiparesis is early, it rather indicates involvement of the 
internal capsule, which also causes hemihypsesthesia. Conjugate devi- 
ation is not common. T emporosphenoidal lesions are largly otitic, 
are frequently latent and are less frequently cortical than subcortical, 
whence the centres are less involved than the deeper association fibers. 
The left side is more important; lesions here lead (in 42 per cent.) to 
sensory aphasia, partial word deafness, alexia, agraphia, amnestic and 
optic aphasia; Korner holds that aphasia is rare. (The right side 
concerns the memory for letters and figures [Oppenheim].) Occipital 
lesions or those in the contiguous parietal, or temporal lobes, or deeper 
in Gratiolet's optic radiation, produce hemianopsia (they occur more 
in traumatic or metastatic than in otitic abscess). Cerebellar abscess 
results almost exclusively from ear disease, and is often latent. Ataxia 
may also be caused by the ear affection or abscess elsewhere, even in 
the frontal lobes. Occipital headache and stiff neck occur; there may 
be a tendency to fall forward (Gravis) or backward (Dupuy), and 
hemiparesis, or yawning may result from compression; cranial nerve 
paralyses are not frequent and result from coincident meningitis. 
Paralyses of the seventh and eighth nerves are often due to bone dis- 
ease. Abscess of the pons, medulla (of which Cassier, in 1903, found 
only 16 cases), and crus is exceptional. (See Cerebral Local- 
ization.) 

Symptoms by Stages. — (a) The initial stage is observed mostly in 
acute traumatic or metastatic abscess. Pus may form in thirty-six 
hours (Martius), but this usually requires ten to thirty days. The 
causal symptoms, those of sepsis and general brain symptoms, appear 
rapidly but focal symptoms usually appear only after one-half to three 
months; death may occur from coma, fever, and meningitis, or the next 
stage may appear, (b) The latent stage has no fever, is seen in chronic 
abscess, probably corresponds with demarkation and encapsulation, 



ABSCESS OF THE BRAIX 1017 

lasts for months, years, or even decades, and is either complete or inter- 
rupted by symptoms of the third stage, (c) In the "manifest" stage, 
symptoms of sepsis and general or focal brain symptoms appear con- 
tinuously or remittently, with evidence of extension. Most cases are 
seen in "this stage. Gowers estimates that after nervous symptoms 
once develop, (d) the next, the fatal or terminal stage, appears in five days 
(20 per cent.), in ten days (33 per cent.), fourteen days (50 per cent.), 
and in thirty days (75 per cent.). This stage may immediately follow 
the latent stage when rupture into the lateral ventricle occurs. 

Diagnosis. — Recognition is impossible in latent cases affecting 
" silent" areas, whence "no brain disease of equal severity so often 
escapes recognition." When focal symptoms are absent, various 
psychoses may be thought of. The diagnosis is often made only in the 
last two stages. Few cases can be detected without consideration of 
the etiology, which is definitive in 75 per cent. (Gowers), the sepsis, 
general and focal brain symptoms. 

Otitic abscess may be confused with the otitis itself especially in 
children; otitis may produce general symptoms, as headache, vomiting, 
convulsions and even optic neuritis (probably due to serous meningitis), 
cranial nerve symptoms (nystagmus, diplopia) but all symptoms dis- 
appear when the middle ear, attic, mastoid or subperiosteal foci are 
cared for; otitic brain abscess runs an acute rather than a chronic 
course, but the various stages may be observed; the period of latency 
rarely exceeds one to one and a quarter years (Korner, Pitt), and 
usually averages two months or less (Pitt). Temperature is often 
lower than in other forms, the headache may be local or unilateral, 
and local oedema may be seen over the temporal region, with tender- 
ness on percussion and a higher percussion note (Macewen). 

Otitis may also cause suppurative meningitis, extradural abscess or 
sinus thrombosis, either with or without brain abscess, from which 
they must be differentiated. The table on page 1018 is borrowed 
from Oppenheim's classical description. 

Serous meningitis (Billroth and Quincke) is often mistaken for the 
suppurative form and is very important in ear disease. It is attended 
by little rise of temperature, internal hydrocephalus, paralysis of the 
basal nerves, often gives a serous fluid on lumbar puncture and is 
often cured. Extradural abscess (external suppurative pachymenin- 
gitis) was found in 78 per cent, of 184 cases of brain suppuration 
(excluding meningitis) by Jansen, sinus thrombosis was found in 18 
per cent., and brain abscess in barely 3 per cent. It is more common 
(43 per cent.) in acute otitis than is abscess (9 per cent.). Local 
symptoms, as cedema and tenderness, are common, but diffuse and 
focal symptoms are not frequent. Sinus thrombosis is more often 
attended by pyemic symptoms, high fever, chills, sweats, icterus and 
foci in the lungs, rapid pulse, choked disk, general convulsions and 
external symptoms of altered brain circulation (see Sinus Thrombosis). 



1018 



DISEASES OF THE XERYOUS SYSTEM 



Etiology: 
Onset: 
Course : 

Fever: 

Pulse: 

Sensorium : 



Headache, vomit- 
ing, vertigo: 

General convul- 
sions: 



Retina : 



Meningitic evi- 
dences: 



Focal symptoms: 



Spinal symptoms: 



Lumbar puncture : 



Brain Abscess (Otitic). 



Diffuse Suppurative 
Meningitis. 



Ear disease. 



Same: favored by imperforate 
tympanum and childhood. 



Acute or subacute, but often Acute, stormy, even apoplectic, 
some latency. 

Acute, subacute, chronic j Acute, stormy, more rapid than 

abscess (66 per cent, last under 
one week) though sometimes 
remissions occur. 



(latency stage), from weeks 
to seldom over one year. 



Normal, subnormal, moder- 
ate. 

Slow. 

Simple dulness, merging into 
coma. 



Headache almost constant; 
others less constant. 



Not frequent. 



Optic neuritis common. 
Choked disk not common. 

Less by far. 

Stiff neck rare save in cere- 
bellar. 



High, continuous and rarely low 
or absent. 

Usually fast and irregular. 

Unrest, irritability, delirium; 
dulness later; sensorium seldom 
normal. 

Headache and vomiting almost 
invariable. 

Usual, clonic and tonic. 



Usually negative because of rapid 
course. 

More common psychical and motor 
unrest, jactitation, hyperesthesia 
of special and general sensation, 
trismus; retraction of abdomen; 
general rigidity. 



sule and sometimes cerebel- 
lar; paralysis of third 
nerve. 



Frequent, especially tempo-j Diplopia, strabismus, unequal 
rosphenoidal, internal cap-j pupils, conjugate deviation, par- 
alysis seventh and eighth nerves ; 
these are diffuse, transitory and 
variable; rarely hemi- or mono- 
plegia; very rarely aphasia, 
hemianopsia (more frequent in 
meningitis tuberculosa). 

Seldom. Few cases of absent Almost always stiffness and ten- 



patellars. 



Rather dangerous. 



derness of neck, back and general 
muscles, Kernig's sign; pares- 
thesia and hyperesthesia, dy- 
suria, involuntary evacuations, 
absent patellars. 
Positive findings (see meningitis). 



Differentiation is sometimes impossible. 

Traumatic abscess develops early, is associated with hematoma, con- 
cussion, contusion, or diffuse meningitis, from which differentiation is 
often impossible or difficult, except that the abscess is slow in evolution. 
Its presence is often suspected because of delayed healing of the wound. 



ABSCESS OF THE BRAIX 1019 

It is usually cortical (whence its focal symptoms), and often provokes 
fever and other general symptoms. It must also be differentiated 
from traumatic hemorrhage, which occurs days or weeks after the 
injury and often in the corp. quadrigemina, pons or medulla; from 
acute encephalitis, whose course is more rapid; from concussion, in 
which the symptoms are more diffuse and may involve the brain 
nerves or arouse fever, though cortical symptoms are absent; from 
traumatic neuroses, which lack focal and septic symptoms (Oppen- 
heim). In late traumatic abscess latency may last in extreme cases, 
even thirty years. The abscess is not cortical (affecting the centres), 
but subcortical (affecting the conduction or association fibers). Cere- 
bral tumor (q.v.) must be considered. 

Abscess by metastasis. It is well known that lung suppuration 
affects the brain with especial frequency, whence the chest must be 
examined; localization is largely in the hemispheres, thus obeying 
the general topography of simple embolism. The Sylvian district 
(and occipital lobes) are most often affected, and the multiplicity of 
localization should be remembered. The course is usually precipitate. 

A diagnosis of idiopathic abscess without proper etiology is always 
unsafe and usually impossible. 

Prognosis. — Spontaneous recovery by demarkation, inspissation and 
calcification (Fenman) is recorded in a few cases, though it is then 
probable that such abscesses are healed tubercles. External rupture 
may exceptionally occur. Without operation, death is practically 
inevitable, (a) from rupture into the lateral ventricles (16 per cent., 
chiefly in metastatic and otitic abscess), and into the membranes (28 
per cent., in cerebellar abscess), (6) from hydrocephalus internus, (c) 
from sinus thrombosis, (d) from pressure on the medulla, (e) from 
brain oedema or rarely hemorrhage. Sudden death may occur, how- 
ever, as in tumor, without adequate postmortem explanation. 

Treatment. — (a) Prophylactic therapy concerns the etiological fac- 
tor. Adequate drainage is always necessary, although granulations 
in the middle ear are protective and should not be curretted in any 
routine manner (precisely as uterine curettage in puerperal sepsis is 
now discountenanced), (b) Palliative treatment is that of brain tumor 
and meningitis. Special care regarding vomiting is indicated, lest 
it rupture the abscess, (c) Surgical intervention is indicated. Suc- 
cessful cases were those of Morand 1868, Roux 1848, and Schede, 
1866, as well as those of Hitzig and Wernicke. Macewen, Barker, 
Greenfield, Ferrier, Horsley, and Schwartze are the pioneers in its 
practical treatment. Von Bergmann's rule was that operation should 
never be performed unless the diagnosis was certain, but adherence 
to this rule would have cost many lives. The contra-indications are 
(a) metastatic abscess, (6) a fatal etiological disease, (c) inability to 
stand the anaesthesia or shock, (d) ventricular rupture and (e) diffuse 
meningitis, although in the last two cases, isolated recoveries are 
recorded. Sinus thrombosis, circumscribed meningitis and incipient 
pyaemia do not contra -indicate operation. In Korner's cases (otitic 



1020 DISEASES OF THE NERVOUS SYSTEM 

abscess), 51.6 per cent, recovered, Oppenheim (traumatic cases) re- 
ported recovery in 45 per cent., Wheeler's series gave 87.5 per cent., 
and Macewen's series showed 96 per cent. 



III. Dementia Paralytica. 

It is also known as paralytic or paretic dementia, general or pro- 
gressive paralysis of the insane, and among the laity as softening of 
the brain. Bayle, 1822, and Calmeil, 1826, first accurately described 
the affection. It is often classed among the mental rather than the 
brain diseases, but it is so important in everyday practice and con- 
stitutes such a large proportion (10 to 25 per cent.) of all insanities, 
that its description is in place. 

Definition. — Dementia paralytica is a chronic inflammation or 
degeneration of the brain, characterized by progressive vasomotor, 
motor and psychical disturbances, and ending in death after two or 
three years. 

Etiology. — (a) Syphilis is the cause in at least 75 per cent, of 
cases (Mendel and Striimpell). That it is not the sole cause is shown 
by its rarity in Egypt and Japan where syphilis is endemic, (b) Other 
causes, as modern life, with its strenuousness, competition, hurry and 
worry must aid the syphilitic toxins wilich cause degeneration of the 
brain after the syphilis is apparently spent (a parasyphilitic affection, 
according to Fournier). Short sleep, dissipation, overwork, city life 
and the so-called civilized life account for its increasing frequency. 
Krafft-Ebbing summarized the etiology as "syphilization and civiliza- 
tion." These causes may cooperate with (c) hereditary nervous taint 
(15 to 20 per cent.), and (d) alcoholism (20 per cent., though this is 
denied by many), (e) Certain occupations, as those of officers, artists, 
and actors, are predisposing factors, and generally speaking, the higher 
classes are more subject to it. Krafft-Ebbing did not find any clergy- 
men among his 2,000 patients. (/) It occurs between the thirtieth 
and fiftieth years, and (g) is 7 to 10 times as frequent in men as in 
women. Other factors are less prominent as exposure to heat, trauma 
of the head, plumbism or chronic toxaemia. 

Pathogenesis. — The causes enumerated probably produce (a) vaso- 
motor paresis in the fore-brain, followed by (6) lymph stasis in the 
cortex and pia mater, (c) degeneration and atrophy of the brain and 
cord, and (d) interstitial inflammation. Though all cases end in 
brain atrophy, opinions still differ regarding the role of the inflam- 
mation; some regard encephalitis interstitialis (chronic meningo- 
encephalitis) as primary (Mendel), and others hold that it is secondary 
to encephalitis parenchymatosa (Tticzek and Wernicke), just as in 
liver cirrhosis it is now thought that the connective tissue formation is 
secondary in time and importance to cellular alteration. 

Pathology. — (a) The calvarium is thickened in 33 per cent. The 
Pacchyonian granulations are often enlarged. (6) The dura in 50 per 



DEMENTIA PARALYTICA 1021 

cent, is thick, opaque, vascular and adherent to the skull (pachy- 
meningitis, which is often hemorrhagic). In attempting to strip off 
the pia, it is found granular and adherent to the brain cortex (in 80 
per cent.), especially over the frontal and motor areas, which are 
supplied by the internal carotid artery. Later the adhesions may dis- 
appear, (c) The gross brain changes are constant. There is less 
opportunity to inspect the brain in the early stages, when it is swollen 
and hypersemic than in the later stages when it is wasted; it may 
weigh but a third or quarter of the normal (40 ounces or 1,260 gm.); 
atrophy affects largely, if not wholly, the areas supplied by the internal 
carotid artery, especially the frontomotor cortex and the island of 
Reil. The gray matter is yellow-gray, soft and wasted, but the atro- 
phied white substance is firm. The convolutions are greatly narrowed 
and the sulci are widened, for the degree of atrophy corresponds to 
the 6 or 8 ounces of serum which fills the deficit (hydrops ex vacuo). 
In 80 per cent, of cases granulations are seen on the ependyma of the 
lateral ventricles, resembling the back of a "cat's tongue," and the 
ventricles contain excess of fluid (hydrops ex vacuo). Areas of 
hemorrhage, softening and cyst formation are due to complicating 
vascular disease, (d) The minute alterations in the brain are as follows : 
the ganglion cells are early swollen and cloudy; the later findings are: 
vacuolated, degenerated and atrophied ganglion cells; wasting of the 
medullary sheaths and of the axis cylinders, especially in the association 
or tangential nerve fibers running parallel to the cortex (Tiiczek), 
which are said to waste before any inflammation can be seen; corpora 
amylacea represent what is left of them; the same changes occur in 
the cranial nerves; the bloodvessels show mural proliferation, exu- 
dation, colloid or hyaline metamorphosis, thickening and later atrophy 
or obliteration; the lymph vessels show proliferation, transudation 
and compression of the cortex, where lymph cysts, from snaring off 
of lymph vessels, sometimes cause cystic degeneration of the cortex; 
the neuroglia increases even sevenfold (sclerosis), (e) Alteration of 
the spinal cord, described first by Westphal, is present in 90 per cent. ; 
the lateral columns often show descending degeneration, but most 
commonly changes like those of tabes are found in the posterior columns 
(column of Goll) and in the posterior roots. Pachy- and leptomenin- 
gitis are seen in 40 per cent. As in tabes, the cerebrospinal fluid contains 
chiefly mononuclear cells. (/) Changes in the cranial nerves, especially 
the first to the seventh, may result from syphilis or alcoholism. 

General Symptomatology. — As a rule, the symptoms are first vaso- 
motor, second psychical, and third motor, in the order of their usually 
slow development. It is possible for the psychical symptoms to appear 
first, with the motor, or more rarely to follow them. The leading 
symptoms are referable to alteration in the frontomotor cortex. Three 
stages are usually distinguished: 1. In the prodromal stage, recogni- 
tion is often difficult, because the first symptoms are equivocal or 
point to (i) neurasthenia because of the "irritable weakness," ready 
fatigue in mental processes, headache or sense of cephalic pressure. 



1022 DISEASES OF THE NERVOUS SYSTEM 

introspection and rheumatic pains. Again, the initial symptoms are 
(ii) congestive, as headache, migraine, especially significant when it 
has not occurred before, or attacks similar to minor epilepsy (petit 
Trial), (iii) Most important are mental changes. The patient is 
described as "not himself" but "he does not remark his own altera- 
tion" (Schule). Krafft-Ebbing gives a lucid picture of these altera- 
tions. The intellect is cloudy; the patient is confused as to time, and 
comes too early to work or remains after time; he confuses places 
and may smoke in church; his observation is faulty as well as his 
judgment; he confuses dreams with actualities, and his memory is 
confused, for he forgets entire epochs, especially recent impressions. 
./Esthetic and social lapses are common; the subject becomes vulgar, 
careless, neglects duties, disregards amenities, and from lack of will 
power may steal or dissipate most openly. Emotional outbreaks occur, 
as violent or brutal conduct, or maudlin sentiment over soon forgotten 
incidents. The patient is often perniciously active, (iv) Focal symp- 
toms, especially amnestic aphasia may appear, (v) General findings 
are noted after a time, as small and unequal pupils or other tabes-like 
findings, double vision, unequal innervation of the face, fibrillary 
contractions of the tongue, tremor, pains, headache, vertigo, congest- 
ive attacks, slow pulse, rough, unmodulated voice, skipping of words 
in reading (paralexia), and irregular, incorrect writing (paragraphia). 
This stage covers months or years. In rare instances the symptoms 
may follow tabes; this is "the ascending form of general paralysis." 
2. At the height of the disease, (i) the psychical symptoms take var- 
ious types, as maniacal exaltation, melancholia, hypochondriasis, or 
simple progressive dementia. Psychical blindness or deafness occurs, 
(ii) Congestive, apoplectiform attacks are frequent, and the general 
findings become more distinct, as immobile and unequal pupils, 
hesitant speech with elision of syllables, altered expression, trembling 
or paresis of the face, incoordination of the hands and gait, disturb- 
ances in writing and reading, and retention of urine. During the 
not uncommon remissions, some of these symptoms can almost always 
be found. 3. The terminal stage is characterized by complete demen- 
tia (the final type of all initial varieties), complete disorder of speech, 
incoordination so extreme as to necessitate feeding the patient and 
keeping him in bed, sensory disturbances, vasomotor paralysis, grind- 
ing of the teeth, trophic complications, and death from pyelonephritis, 
bed-sores, complications or bulbar symptoms. 

Symptoms in Detail. — Psychical Symptoms. — The weakness, altera- 
tion in character, loss of memory and reason, and the ethical, aesthetic, 
and moral loss have been described. During the height of the dis- 
ease there is one of three main mental manifestations : (a) megalomania, 
with simple exaltation or mania. This classical expansive type occurs 
in 66 per cent., is associated anatomically with the characteristic 
meningo-encephalitis, and is characterized by ideas of grandeur, the 
patient believing he is a king, God, a millionaire, an athlete, etc. He 
makes ridiculously large plans, buys extravagantly, lacks will power, 



DEMENTIA PARALYTICA 1023 

indulges himself excessively, changes with great "facility" from one 
thing to another, is optimistic, friendly, even philanthropic, and rap- 
idly runs through his capital. He loses himself, forgets names, and 
confuses the real with the unreal. Periods of acute mania, with fever, 
and grinding of the teeth are expressions of brain congestion; com- 
plete dementia is the final outcome, even though remissions occur, 
during which some mental or somatic change can be detected. (b) 
The melancholic or hypochondriacal form is thought to occur with 
cystic degeneration of the cortex. It may be of the dull or agitated 
type. The patient dwells on the condition of his bowels; one subject 
thought that they would "burst and flood the world." There is often 
micromania, characterized by "self-belittlenient," in which the indi- 
vidual fears everything and thinks himself a "dot, nothing, or denies 
his existence." These cases may commit suicide. Dementia is the 
outcome, (c) Simple 'primary dementia may be present from the 
beginning; this type is increasing in frequency, while the first classical 
form is decreasing. It is thought to be based anatomically on simple 
cortical atrophy in which inflammation is absent or late and secondary. 
These subjects are often deceptive in the early stage, being quiet, 
urbane and optimistic. In the ultimate dementia of all types, mentality 
is wholly gone, "there is no sense of time, place or identity," and the 
patient babbles or is speechless. 

Motor Disorder. — This usually occurs with mental changes, is con- 
stant, though variable in its expression, incomplete in degree, extensive 
as to parts involved, and progressive, (a) Speech is pathognomonically 
disturbed as a result of mental change, wasting of association fibers 
and later of bulbar atrophy. It is incoordinate, involving letters 
{"literal" ataxia) or syllables. In pronouncing such words as "elec- 
tricity" the patient characteristically stutters over syllables. It is 
worse in the morning and after resting. Loss of word memory is the 
primary trouble; the patient forgets expressions, speaks ungram- 
matically and "does not notice it." Speech becomes atactic, there 
is paraphasia, the voice is unmodulated, gives out suddenly, is some- 
times hoarse, nasal or slow, but never scanning. Later, speech is 
disturbed from bulbar alteration, causing dysarthria from .disease of 
the facial and hypoglossal nuclei; it is ultimately unintelligible (abso- 
lute aphasia). Closely associated with speech disturbance is (b) 
disordered reading (paralexia), which is rather characteristic and occurs 
early, (c) Writing is disturbed first because of the mental alteration; 
the patient has difficulty in collecting his thoughts, although he does 
not realize the cause (the ataxia by which he drops syllables, repeats 
words or sentences — paragraphia); and it is disturbed secondly be- 
cause of tremor. The writing is uneven, up and down or zig-zag. 
These changes are diagnostic, (d) Paralysis of the eye muscles (in 
6 per cent., Marie) is usually partial and transitory. When total, 
syphilis or tabes is the probable cause, (e) The pupils: Myosis may 
occur, often just before maniacal outbursts. Mydriasis is frequently 
unilateral and results from irritation of the sympathetic nerve. In 



1024 DISEASES OF THE NERVOUS SYSTEM 

60 per cent, of cases, the pupils are now large, now small, and 
this is considered as especially ominous. They are often irregular or 
triangular. The Argyll-Robertson pupil, responding to accommo- 
dation but not to light, usually appears early, is marked in 47 per 
cent., partial in 20 per cent, and absent in 33 per cent. Reichert 
holds that it is always due to degeneration in Bechterew's column 
(i.e., between that of Goll and Burdach). (/) The facial nerve: 
The paresis of the lips is cortical, as are fibrillary twitchings in speak- 
ing or mimetic movements, automatic chewing movements, and 
almost constant grinding of the teeth. The "fatuous" or " masked" 
expression is psychical. Salivation results from cortical irritation. 
There may be difficulty in swallowing, (g) The limbs: (i) The 
cortical changes cause the small-waved, rapid, constant tremor, 
the ataxia, loss of muscle sense, and the uncertain, ungraceful, 
tripping, paralytic gait, (ii) The gait may be tabetic, with ubsent 
knee jerks, immobile pupils and vesical symptoms; or it is more 
often spastic with increased patellar reflexes, ankle clonus, contractures 
and changes in the joints. The patellars are usually increased 
in the early stages, (iii) Neuritic atrophy of the cranial nerves 
may occur as in tabes, (h) Apoplectiform and epileptiform attacks 
may occur. (i) Apoplectiform seizures result from vasomotor 
paralysis and brain oedema, and differ from apoplexy in their incom- 
pleteness, evanescence, increased temperature and increased reflexes. 
They last part of an hour, and may produce temporary hemiplegia, 
but especially aphasia with paresis of the right arm. (ii) Epileptiform 
attacks occur later, result directly from cortical disease, are usually 
partial (involving the face or arm), and are either Jacksonian or are 
attended by partial loss of consciousness; conjugate deviation of the 
eyes and increased temperature are also observed. They are not 
frequent but, once initiated, recur and aggravate the mental alienation. 

Sensation and Special Senses. — Coincident neurasthenia, tabes and 
pachymeningitis may emphasize the sensory manifestations, as the 
lancinating pains of the tabetic form. Sensation is often dulled and, 
like the analgesia, is cortical in origin. It is thought that the hypo- 
chondriacal complaint that certain organs, as the bowels, are absent, 
is due to visceral anaesthesia. Attacks of migraine, when they first 
appear late in life, may indicate an organic origin, and Charcot 
described a form with hemianopsia and symptoms like glaucoma. 
Migraine is cortical when associated with paresis of the face, tongue 
or arm. Alteration of the special senses includes optic neuritis and 
atrophy (4 per cent.), optic hallucinations and psychical blindness. 

Other Symptoms. — (a) Vasomotor changes occur in the skin (livid- 
ity, oedema and sweating) and in the brain, lungs, bladder, intestines 
and stomach (resembling the so-called bilious attacks). (b) Trophic 
symptoms are sweating of blood, rough skin, phosphaturia, perforat- 
ing ulcer of the foot (3 per cent.), bed-sores and friability of the bones, 
which may be broken without the patient knowing it. The "insane 
ear" is frequent. Many of these symptoms are spinal and neuritic. 



DEMENTIA PARALYTICA 1025 

General Symptoms. — The pulse is often slow and monocrotic, the 
temperature low, although the heat centres may be involved in conges- 
tive seizures with great febrile elevation, and the body weight is often 
reduced in the early and late stages, though at the height of the dis- 
ease it often increases, especially before the congestive seizures. The 
sexual instinct, at first increased and sometimes perverted, later de- 
clines. Insomnia may be severe, may last for months, and sometimes 
is absolute. 

Diagnosis. — The diagnosis depends upon (a) the etiology, as syphilis 
with mental strain, head trauma, or excesses; (b) the grouping of the 
psychical symptoms, as character, aesthetic or ethical changes with 
(c) motor symptoms, as the speech, writing or tremor; (d) vasomotor 
symptoms, as migraine or apoplectiform insults, and (e) the progressive 
course. 

Differentiation. — 1. Diffuse Brain Diseases. — (a) Cerebral syphilis 
may be confused with diffuse meningo-encephalitis of the convexity. 

Progressive Paralysis vs . Syphilis . 

Headache absent or vague and transi- Headache present and severe. 
tory. 

Psychical alteration characteristic; Somnolence, variability in mental symp- 

mental symptoms are coordinated. toms. Merely coincident. 

Epileptiform mono- or hemiplegic seiz- More frequent, 
ures rare. 

Focal symptoms very rare. Focal symptoms common, together 

with diffuse symptoms. 

Greater speech disturbance, literal para- Less or no tremor; speech far less fre- 
phasia, and fibrillary tremor of face quently disturbed; no literal para- 

and tongue. phasia. 

Argyll-Robertson pupil. Absent: oculomotor affections and optic 

neuritis much commoner. 

Progressive, slower. No therapeutic re- In installments, more rapid jumps, re 
suits. missions. Therapy helps or possibly 

cures. 

A parasyphilitic disease. Active syphilis 

(b) Diffuse cerebral sclerosis presents no clear picture and cannot be 
diagnosticated; though it leads to dementia and attacks of delirium, 
there is not the speech and mental alteration which is present in general 
paresis, (c) Senile dementia seldom occurs until after sixty years of 
age. Its course is longer, the symptoms more gradual and less intense, 
memory is maintained longer and there is less megalomania than fear 
of persecution and poisoning, (d) Multiple sclerosis occurs earlier, 
has no syphilitic etiology, is complicated by late and mild mental 
symptoms and an intention tremor, which is wider in amplitude and 
ceases during repose. The speech is scanning, staccato, and there is 
no literal ataxia. Nystagmus is common, while it is rare in general 

65 



1026 DISEASES OF THE NERVOUS SYSTEM 

paralysis. Motor symptoms are largely referable to disease of the 
lateral columns. 

2. Focal Brain Diseases. — (a) Although migraine, headaches, apo- 
plectiform attacks and partial sensory or motor irritation of the Jack- 
sonian type may occur in brain tumor, it does not cause difficulty in 
pronouncing syllables, peculiar mental alteration, or immobile pupils; 
it is characterized by general symptoms, as choked disk, or vomiting 
and focal symptoms, which are foreign to general paralysis. In tumor 
there is simple dulling of the intellect and dementia only with marked 
internal hydrocephalus, (b) Hemorrhagic pachymeningitis compli- 
cates 20 per cent, of cases of dementia paralytica; when it exists as 
an independent affection, it often leads to intense local headache, 
vomiting, recurrent hemiplegia or monoplegia, cortical irritation, and 
more rapid course, (c) Softening usually produces focal symptoms. 

3. Psychoses and Neuroses. — (a) Mania and hypochondriasis may 
require differentiation. Every case of mania between the twenty-fifth 
and forty-fifth year not due to alcoholism or to acute somatic disease 
should arouse suspicion of general paralysis (Mendel). The same 
may be said of hypochondriasis, (b) Neurasthenia may be confused 
with dementia, and the etiology may be identical. In neurasthenia 
the onset is more acute; headache accompanies the lassitude and 
"irritable weakness/' the memory is fatigued but never lost, the 
patient recognizes his incapacity; and oxalates and urates abound in 
the urine. In dementia paralytica, however, there is phosphaturia, 
hypochondriasis with absurd conceptions, changes in the pupils, disk 
and field of vision, alterations in character, speech and intellect which 
are never seen in neurasthenia. 

4. Intoxications. — These may produce many of the symptoms of 
dementia paralytica and may cause many of the forms known as 
general pseudoparalysis which are due to alcohol, lead, etc. (a) 
Chronic alcoholism is not progressive, recovery is frequent, delirium 
tremens and convulsions are common, the course is acute covering 
but weeks or months, and the alcoholic tremor, headache, hallucina- 
tions, and neuritis are found, (b) Chronic plumbism (saturnine enceph- 
alopathy) is often progressive, even fatal, and in its last stages indis- 
tinguishable from dementia paralytica. It is more acute, and 80 per 
cent, of the cases recover. There is headache, cardiac distress, ansemia, 
and gingival lead line, (c) Chronic bromism is distinguished by its 
stupor, dementia, bromide acne, foetid breath, coated tongue, pharyn- 
geal anesthesia, weak heart and acute course, which usually ends in 
recovery. 

Prognosis. — The disease is fatal within three years and in 66 per 
cent, of cases within two years, though remissions may occur. Krafft- 
Ebbing saw no recoveries in 2,500 cases; if recovery occurs the 
diagnosis is probably incorrect and the disease is considered pseudo- 
paralysis generalis. The following courses are distinguished: (a) 
acute or galloping form, which lasts months or a year; (b) classical, 
expansive type, which lasts three to four years and in which the prog- 



CHRONIC PROGRESSIVE SOFT EX IX G 1027 

nosis is the most favorable; (c) the depressive type, which lasts two to 
three years; (d) dementia forms, which last four to five years; (e) 
circular form, in which depression alternates with mania ; (/) female 
variety which has a longer course than in males; (g) spinal form, with 
a relatively long course; (h) juvenile or adolescent; and (i) senile form. 
Death results in 50 per cent, from the disease itself, by apoplectiform 
seizures, suicide, inanition or bulbar symptoms. In 50 per cent, it 
results from complications, tuberculosis (18 per cent.), bed-sores, with 
sepsis (10 per cent.), lung gangrene (6 per cent.), pneumonia (5 per 
cent.), choking (10 per cent.), and cystitis. 

Treatment. — (a) Etiological treatment. Recovery is barely pos- 
sible in the early stages, and many physicians advise that mercurial 
inunctions be given. It must be recalled that the disease is a 
meta- or parasyphilitic disease, not active syphilis, and that some 
consider mercury distinctly injurious. Iodides promote resorption and 
favor a milder course, (b) Hygienic treatment, as rest, protection 
from heat, and quiet surroundings, is indicated, (c) The patient 
should be put in an asylum, for suicide or other violence is always 
possible. In the simple dementia form, alone, may the patient be 
treated at home, (d) Hydrotherapy is valuable within limits. Cold 
rubs lessen excitation, although full cold baths are contra-indicated. 
(e) Medicinal treatment is unsatisfactory. Drugs produce dispropor- 
tionate effects and must be exhibited with caution. For delirium and 
insomnia bromides are most efficacious, but chloral and opiates should 
be given less frequently or only in combination with hyoscine, digitalis, 
and bromides, or with the ice-cap. Ergot is said to produce remis- 
sions, but is valuable chiefly as a vascular tonic for brain congestion. 
(/) The skin, bladder and rectum should receive treatment as in 
apoplexy and spinal diseases. 



(E). DEGENERATIONS OF THE BRAIN. 

I. Cystic Degeneration. 

Cystic degeneration occurs mostly in the shrunken brain of aged 
persons, and largely in the perivascular spaces of the cortical and 
basal white substance. No essential symptoms result from the fluid; 
they are those only of the causal atrophy. Possibly the vessels are 
prone to dilate and rupture from shrinkage of the brain and conse- 
quent lack of support. 

II. Chronic Progressive Softening. 

Chronic progressive softening, when not due to vascular disease, is 
a rare affection; it was described by Wernicke. It affects the white 
matter chiefly, occurs mostly after the sixtieth year, its pathogenesis 



1028 DISEASES OF THE NERVOUS SYSTEM 

is obscure, and its clinical symptoms are weakness on one side, slight 
irritative phenomena, as tingling or pain, and involvement of the 
intellect. The length of the course varies from a month to a few years, 
and remissions are uncommon. 



III. Multiple or Insular Sclerosis.— (See Spinal Cord.) 

IV. Diffuse Sclerosis. 

This may involve one or both hemispheres of the brain or cere- 
bellum, (a) It is often secondary to meningeal hemorrhages at birth, 
infantile hemiplegia, arrest of development, and trauma. In these 
cases the sclerosis is secondary to brain atrophy, (b) In other cases 
there is sclerosis without atrophy. The causes are congenital syphilis, 
chronic alcoholism, contracted kidney or other exhausting diseases. 
The symptoms are indefinite. Hemiplegia, impaired mentality, con- 
vulsions, contractures, spontaneous movements (Strumpell), vertigo, 
syncopal attacks and slow speech have been noted. Miliary sclerosis 
is very rare and consists of minute foci in the cortex, where the gray 
and white substance join. Many reported cases are due to artefacts 
in hardening. 

V. Atrophy of Brain. 

Genuine atrophy is always acquired. It is often associated with 
microcephaly, and the brain is usually normal. Unilateral atrophy is 
observed in some cases of chronic insanity. Local atrophy may occur 
anywhere, is usually associated with sclerosis (q. v.) or neuroglia in- 
crease, is usually acquired and is very often secondary to previous 
trauma, tumor, or hydrocephalus. Some reported cases are clearly 
agenesis and arrested development. The symptoms are not distinctive. 
Hemiplegia, hemiathetosis and imbecility may accompany the infantile 
forms; they occur bilaterally when both hemispheres are diseased. 
Senile atrophy occurs in old age, when the brain becomes smaller and 
firmer and hydrops ex vacuo occurs in direct proportion to the shrink- 
age. Mental changes are not as common as is usually stated. 

VI. Hypertrophy of the Brain. 

This is most infrequent. Increase of the neuroglia is sometimes 
present and so-called local hypertrophy is frequently only gliomatous 
infiltration. Hypertrophy occurs at birth, in the first year, when it is 
often associated with rickets, and sometimes in older children or in 
adults. A family tendency is said to exist. The skull is enlarged, 
the ventricles decreased, and the convolutions are flattened. Coincident 



CHRONIC BULBAR PARALYSIS 1029 

hypertrophy of the lymphatic glands, thyroid and thymus has been 
observed. The symptoms are vague and diagnosis is impossible. 



VII. Chronic Bulbar Paralysis. 

Although mentioned by Robinson (1815), and Dumesnil (1859), 
this affection was first thoroughly described by Duchenne (1860), as 
labioglossopharyngeal (laryngeal) paralysis, and his observations 
were confirmed by Trousseau, who made the first autopsies. Wachs- 
muth (1864) advanced the name, progressive bulbar paralysis, and 
Charcot and v. Leyden demonstrated alteration in the bulbar nuclei. 

Etiology. — Most cases occur in persons between fifty and seventy 
years of age, although some are observed in children, and sometimes 
in the same family. Heredity is a factor only when the disease is 
associated with progressive muscular atrophy. Sixty-four per cent, 
of cases occurs in males. Trauma, cold, infections, mental or physical 
exhaustion and toxaemias, are uncertain factors. Rheinhardt holds 
that it may follow acute inflammation of the medulla. 

Pathology. — To the naked eye the medulla usually appears normal, 
though sometimes shrunken. Microscopically, (a) the motor nuclei 
are symmetrically and bilaterally wasted, their cells and processes 
shrunken. The hypoglossal nucleus suffers most, and few normal 
cells remain; its accessory nucleus is usually normal. The spinal 
accessory nucleus is next most frequently affected, but the vagus 
nucleus suffers less. Degenerative atrophy may invade the glosso- 
pharyngeal or exceptionally the facial and fifth nuclei. In some cases 
(Eisenlohr), perivascular exudation occurs within the nuclei, and the 
nerve elements are degenerated (the parenchymatous form), but in 
others increase of connective tissue or thickening or multiplication of 
the bloodvessels may be seen, (b) The respective nerve trunks in 
their course or in their terminal intermuscular endings, are soft, gray 
and show parenchymatous and interstitial change. This may occur 
even within the medulla, and the posterior longitudinal fibers waste 
in direct ratio to the hypoglossal nuclear atrophy, especially those 
which form the anterior fundamental fibers of the spinal cord. Some- 
times the loop of the seventh nerve wastes, although the cause is not 
clear, (c) The muscles supplied by the above nuclei and nerves 
waste, as those of the lips, tongue, palate and larynx (the process 
sometimes extends to the neck and arms). The greatest change is 
in the tip of the tongue. The changes are those of progressive muscular 
atrophy, i. e., atrophy which is unequal in its distribution, as granular, 
fatty or waxy alteration, increased nuclei in the muscular sheaths and 
in the connective tissue, reddish pigmentation, and sometimes over- 
growth of the fatty tissue. The nuclei of the medulla are rarely the 
sole seat of the disease, and when they are alone affected, the disease 
runs a rapid course of a few months to a year (Remak) , suggesting 
that other structures have not time to be affected, (d) In many 



1030 DISEASES OF THE NERVOUS SYSTEM 

cases the pyramidal tracts show degeneration, which may be traced 
down into the cord or up into the cms. 

Symptoms. — Labioglossopharyngeal paralysis, the name proposed 
by Duehenne, designates the parts paralyzed by the wasting of the 
motor nuclei. It is almost invariably bilateral, and but one case 
showed unilateral disease. It is slow in onset, afebrile and painless. 
Initial dyspnoea and headache are exceptional; the first symptom is 
usually paresis of the tongue (hypoglossus) which first shows fatigue 
and much later actual paralysis. It is difficult to protrude or move 
up, down or transversely. The Unguals, L, X, R, and S are formed 
with difficulty and also later the lingual palatines, as T and D. The 
tongue is sometimes large and flabby, but more often wrinkled and 
wasted. The lips become weak; and kissing, whistling and formation 
of the labials (O, U, P, B, M) becomes impossible. At first sight it 
seems strange that paralysis of the tongue and lips should be so closely 
associated, yet physiologically they are more closely associated than 
any other muscles of the body; anatomically it is probable that the 
facial fibers for the orbicularis oris originate in the hypoglossus nucleus 
or arise very close to it. Forced attention may for a while overcome 
imperfect enunciation, but later the paralysis is complete, the mouth 
cannot be closed, the lower lip sags and the zygomatic muscles over- 
come the weak fibers of the upper lip, and accentuate the nasolabial 
furrow. The lips are frequently thin, but may appear normal. The 
expression is peculiar, the forehead is corrugated, the eyebrows some- 
what lifted, but the mouth is passive, its expression is "dead/' and 
laughing and emotional displays produce a strange effect, which Trous- 
seau compared to the mask of the Greek actors. The original descrip- 
tions graphically picture the patient constantly holding a handkerchief 
before the lips to collect the free flow of saliva from the open mouth; 
the salivary secretion is probably also increased from disease of its 
bulbar centre. The chin muscles are also weak. Sicalloicing becomes 
difficult from the inability of the tongue to propel the food to the 
pharynx, so that the subject must push the food back with the finger, 
and again the palate (which is controlled by the spinal accessory and 
vagus nerves) is weakened, producing a nasal voice and allowing food 
to regurgitate into the nose. The pharynx is also paretic (it is supplied 
by the glossopharyngeal and vagus nerves), and the larynx suffers 
(spinal accessory and vagus nerves). Semi-solid food can best be 
swallowed, because fluid more easily regurgitates into the nose, and 
solids more easily reach the larynx. The larynx is often involved. 
The adductors are much more often affected than the abductors, but 
the palsy is usually incomplete. Talking and coughing are difficult 
or impossible. Fibrillary ticitchings are very common, sensation is 
normal, but the reflexes of the skin and mucosa are usually lost, 
which may possibly be the first sign of the disease (Krishaber). The 
electrical reactions are seldom much changed, though there is some- 
times a partial or mixed form of reaction of degeneration. The intel- 
lect is normal. The patient may be somewhat emotional, and forced 



CHRONIC BULBAR PARALYSIS 1031 

laughing and weeping are not uncommon. The general nutrition 
suffers from the dysphagia. In some cases the process extends beyond 
the nuclei mentioned; the eyes may be involved, as in progressive 
nuclear ophthalmoplegia (which is an identical process in the pons), 
chiefly in young subjects and in "family forms"; occasionally the 
cervical, facial, masseteric, temporal and pterygoid muscles are in- 
volved; affection of the latter was considered ominous by Duchenne. 
The optic nerve is very rarely implicated. Bulbar paralysis frequently 
co-exists with progressive muscular atrophy of spinal origin, affecting 
the limbs or trunk, and Kussmaul first pointed out that the two pro- 
cesses are identical in nature and differ only in location. The spinal 
disease may progress upward to the medulla, causing secondary bulbar 
palsy, or the bulbar palsy may be primary, followed by the secondary 
and analogous spinal atrophy. In the typical case of bulbar paralysis 
there is wasting, paralysis and absence of the reflexes. In some 
atypical forms there is paralysis but no wasting, and at times the reflexes 
are increased (clonus in the muscles of mastication); in these cases 
it is probable that the lesion is in the supranuclear fibers, and this is 
"the bulbar analogue of amyotrophic lateral sclerosis of the cord," 
with which it may also be combined later. 

In the progressive course of the malady, the pulse becomes rapid 
(120 to 150), and irregular; tachycardia is often preceded by running 
together of the heart tones, which Duchenne compared to the "heart 
beating in water." Respiration is difficult, dyspnoea develops and the 
expiration is weak. 

Diagnosis. — This is based on (a) the distribution of the process in 
the motor nuclei; (b) its bilateral symmetry; (c) gradual onset, and (d) 
chronic progression. Neuritis of the bulbar nerves is very rare; the 
lips escape, because the nerve fibers to the orbicularis oris, arising in 
or near the hypoglossus nuclei run to the pons and leave it by the 
facial nerve fibers; there is more atrophy, more rapid course, more 
sensory disturbance and the reaction of degeneration is present. It 
occurs in acute infections, in leuksemia, etc. Brain tumor within the 
medulla occurs most often in young subjects and gives the general 
and local signs of tumor; growths, exostoses, dislocations, caries or 
aneurysms without the medulla but rarely produce bilateral or exactly 
symmetrical paralysis ; the lips escape, dysphagia is the leading symp- 
tom and other symptoms foreign to bulbar palsy develop, as motor 
irritation, convulsions, vomiting or hemiplegia (see Brain Tumors, 
Medulla page 1005). The bulbar symptoms of multiple sclerosis, 
and syringomyelia are almost never symmetrical. Pseudobulbar 
paralysis may be confused. Bilateral disease of the cerebral hemi- 
spheres, sometimes in the cortex, but more often in or near the internal 
capsule, especially when due to arterial lesions, may cause dysarthria 
(Joffroy, 1872). One lesion may be in the cortex and the other in the 
lenticulostriate area (Halipre); Jolly found this condition in sym- 
metrical sclerosis of both hemispheres. Pseudobulbar palsy causes 
cerebral symptoms, as mental change, aphasia, hemiplegia, double 



1032 DISEASES OF THE XERYOUS SYSTEM 

facial paralysis, and hemianopsia; one side is involved after the other 
and it is attended by no wasting, no loss of reflex action and no reaction 
of degeneration. 

Prognosis. — The disease is almost invariably fatal in one to three 
years (or seven), especially in advanced life or when co-existent with 
spinal muscular atrophy. Remissions are possible, and in the rarest 
instances the disease mav be arrested in vouth or middle life. Death 
results from inanition, inhalation pneumonia, intercurrent disease or 
paralysis of the cardiac or respiratory centres. 

Treatment. — Treatment is discouraging. Nutrition must be main- 
tained by feeding with the nasal catheter, to which a funnel is attached. 
Iron, arsenic and strychnine may be given. Electrotherapy is of little 
value. Faradization of the neck and tongue may help deglutition; 
the positive pole should be applied to the spine and the negative 
pole to the throat. The disease steadily progresses in spite of treatment. 

Asthenic Bulbar Palsy; Myasthenia Gravis. 

Chronic bulbar palsy without anatomical lesion may be discussed 
in this connection. It was first described by Wilkes (1877), then by 
Erb (1879), who recognized its light forms, by Goldflam (1891), who 
with Oppenheim published reports of severe and fatal cases. It is 
sometimes known as the Erb-Goldflam syndrome. E. Bramwell has 
collected 90 cases. Its etiology is unknown, but it occurs most often 
in persons under the thirtieth year, and in 25 per cent, a neuropathic 
heredity is demonstrable. The cardinal feature is extreme exhaustion 
{myasthenia) after the slightest exertion. Weakness slowly develops in 
the eyelids, face, palate, masseters, pharynx, vocal cords and the tongue 
although but slightly expressed by ptosis (the first symptom in 33 per 
cent, of cases), dysphagia, dysarthria, and difficult mastication, and 
disappears after rest, to return anew after a few muscular efforts. 
In six cases myasthenia was confined to the eyes. From these bulbar 
symptoms the affection is also called asthenic bulbar paralysis. In 
some cases the arms, legs and trunk are similarly involved, so that 
walking, or arm movements become impossible after short exertion; 
this, together with the bulbar symptoms, is known by the term myas- 
thenia gravis pseudoparalytica. The symptoms are symmetrical. 
The myasthenic reaction of Jolly consists of normal tetanic response 
to faradic stimulation, but becoming weaker with each repetition, 
until at last no reaction is elicited. The reflexes are normal or perhaps 
exaggerated but soon also become exhausted. Some atonicity of the 
digestive tract is fairly common. The mind, special senses, sensation, 
muscles and sphincters are normal, although Collins noted a rapid 
exhaustion of the special senses. Remissions are usual, four years 
being the maximum clinical duration. About 40 per cent, of cases die, 
from exhaustion of the cardiac and respiratory centres but the autopsy 
findings are negative (in 66 per cent) or doubtful. Kalisher found 



APOPLECTIFORM BULBAR PARALYSIS 1033 

hemorrhages in the medulla, and C. Mayer found vascular and nuclear 
alterations. Lymphoid cells have been found between the muscle 
bundles, and Hun and Blumer describe lymphoid and glandular 
hyperplasia in the thymus gland. The diagnosis is based on (a) 
absence of atrophy; (b) absence of reaction of degeneration; (c) 
absence of twitchings and sensory phenomena; id) the presence of 
muscular adynamia occurring with (e) remissions in the course of 
the disease; (/) Jolly's myasthenic reaction; (g) the slight involve- 
ment of the hypoglossus. 

Treatment. — Rest and massage are helpful, but iodide and strych- 
nine are less useful. Galvanization of the head and neck is recom- 
mended by Goldflam, who has reported recovery from its use. 



Apoplectiform Bulbar Paralysis. 

Sudden or apoplectiform bulbar paralysis does not properly come 
under degenerative brain disease, but deserves discussion in this place 
for the sake of topical differentiation. Its usual causes are hemorrhage, 
embolism, thrombosis, and less frequently bulbar encephalitis, trauma 
or compression, bulbar neuritis, the ascending paralysis of Landry, 
and paralysis after acute infections. Its symptoms are as follows: 
(a) The onset is apoplectiform with symptoms (which are rarely focal) 
as vertigo, vomiting, dyspnoea, yawning, slowed heart, which often 
occur without coma. They may progress or regress. (b) Motor 
symptoms are frequent, as double hemiplegia; monoplegia is possible, 
or if the lesion occurs at the pyramidal decussation, there may be 
hemiplegia cruciata, i.e., paralysis of one arm and the opposite leg. 
A unilateral focus may produce bilateral symptoms, which, however, 
are rarely wholly symmetrical. The pyramidal tracts in the medulla 
are supplied by the inferior cerebellar artery. Descending pyramidal 
degeneration follows severe involvement of these tracts, (c) Sensory 
symptoms may develop, as hemiataxia, or hemiansesthesia, (possibly 
without disturbance of muscle sense), id) The bulbar nerves may be 
affected; paralysis of the tongue, pharynx, masseters, larynx, and, 
because of the vascular supply, frequently of the eyes, face and other 
pons centres may result. The reflexes of these parts are often sus- 
pended, though in the extremities they are increased. The lesion 
may be at the level of the nuclei, or supranuclear. The hypoglossal 
and spinal accessory nerves are supplied by the anterior spinal and 
vertebral arteries; the vagus, glossopharyngeal and auditory nerves by 
the vertebral; the fifth, seventh and eye-nerves (third, fourth and 
sixth) by the basilar artery. There may be hemiplegia with paralysis 
of the opposite side of the tongue if the lesion is in the anterior part of 
the medulla. 

The diagnosis is usually easy from the acuity of the lesion in the 
medulla. Chronic bulbar palsy is excluded by the onset and the asym- 
metry and irregularity of the bulbar symptoms, as double hemiplegia , 



1034 DISEASES OF THE NERVOUS SYSTEM 

which is unequal on the two sides, or dysphagia without paralysis 
of the tongue or lip. Exact differentiation between hemorrhage, 
embolism and thrombosis is frequently impracticable. Pseudobulbar 
paralysis of cerebral origin presents the characters of disease of the 
hemispheres and is clearest when one attack is followed by a second. 
Differentiation is impossible should lesions in both hemispheres occur 
simultaneously. 

The prognosis is most grave at the onset, but later there is less 
danger of progression. Improvement and even recovery are possible. 
Treatment concerns chiefly the underlying vascular disease, as in 
hemorrhage, or embolism (q. v.). 

VIII. Progressive Nuclear Ophthalmoplegia. 

This is a degenerative atrophy of the oculomotor nuclei, similar 
pathologically to chronic bulbar paralysis. It is more conveniently 
considered under affections of the third nerve (q. v.). 

(F). HYDROCEPHALUS. 

Acute hydrocephalus is an acute accumulation of fluid either between 
the dura and the brain (acute external hydrocephalus) or in the ven- 
tricles (acute internal hydrocephalus). In some cases the fluid is a 
transudate, being part of a general oedema resulting from cardiac or 
renal disease, or being due to local causes, as sinus thrombosis. In 
most cases it is an exudate. Acute meningitis is the only certain cause 
of acute hydrocephalus, and is most often tuberculous (80 per cent.); 
it is less often the serous meningitis of Billroth and Quincke. It is 
difficult to distinguish between transudation and exudation, and diag- 
nosis is uncertain. Quincke thinks some cases are angioneurotic. 

Chronic Hydrocephalus. 

External form (fluid between the dura and brain). — The causes are 

(a) compensatory hydrops ex vacuo, occurring where brain develop- 
ment is arrested (the congenital form) or when the brain wastes (paretic 
dementia, softening, hemorrhage, sclerosis, senile atrophy, poren- 
cephaly). The hydrops is a transudate under the dura in the arachnoid 
meshes, or between the pia and brain, and has no clinical importance. 

(b) Stasis, as in sinus thrombosis; and (c) chronic diseases, as cancer, 
nephritis or alcoholism are also causes. The symptoms are indeter- 
minate. 

Chronic Congenital Internal Hydrocephalus. 

The etiology is uncertain. It has been thought that the cause was 
foetal meningitis, inflammation in or obstruction of the choroid plexus, 



CHROXIC CONGENITAL INTERNAL HYDROCEPHALUS 1035 

or obstruction in the branches of the vena Galeni, in the lymphatics, 
in the lateral apertures of the fourth ventricle near the glossopharyn- 
geal roots, in the aqueduct of Sylvius, or in the foramen of Magendie 
or Luschka. Hereditary influences and syphilis (10 per cent.) are 
sometimes suggested; parental alcoholism and trauma are questionable 
causes. 

Symptoms and Pathology. — The head is large and may be an obsta- 
cle to labor. It may measure over 5 feet (167 cm.) in circum- 
ference. If it appears after the seventh year, the head is not enlarged, 
and in cretins the head may be undersized. Often the head cannot be 
held upright. The skull is thin, even membranous and translucent 
to the candle test. If the disease halts, the bones may here and there 
thicken, and Wormian bones may develop. The head projects beyond 
the base, the sphenoid is luxated forward and downward, the ear 
meatus points downward, the occiput is forced back, the sella turcica 
is flattened and widened, the roof of the orbit may be pushed down 
so as to become palpable, the fontanelles are large, the fissures gape, 
and fluctuation may be felt. The hair is thin, the veins are large and 
a systolic murmur may be heard, the cause of which is doubtful. The 
brain is pale and may be flattened almost beyond recognition. The 
membranes are often thickened, and the ependyma are often thick, 
granular and sclerotic. The average amount of fluid is 1 quart, 
the maximum 13 quarts. The ventricles, especially the lateral, are 
enlarged; sometimes the third or fourth ventricle escapes. The 
enlarged third ventricle easily compresses the optic chiasm. The 
foramen of Monroe is often very large. The fluid is usually clear, 
sometimes slightly yellow, and rarely blood-stained. It may contain 
epithelial flocculi; it is neutral or alkaline, its specific gravity is 1,001 
to 1,009, the albumin is 0.2 to 2.0 pro mille; and nuclein, fibrin, urea, 
cholestearin, a leucin-like body, and sugar, are found. More than 2.5 
pro mille of albumin or a specific gravity higher than 1,009 indicates 
inflammation, according to Huguenin. 

The face is small, triangular, and the eyes are prominent. Much 
of the sclera is shown and the upper lid is small, though the lower lid 
may cover much of the iris. Nervous symptoms are not unexpected, 
for the brain may be reduced to a small fraction of an inch in thick- 
ness, and is a mere flask for the fluid. The demarkation between gray 
and white matter is lost and in marked cases the convolutions and 
sulci are obliterated, the basal ganglia flattened, the cerebellum forced 
into the spinal canal, and many structures, such as the fornix or corpus 
callosum have disappeared. Mentality, as a rule, is impaired or 
abolished, speaking is learned late if at all, will power is lacking, and 
irritability is common. Patients are prone to psychoses. Epilepti- 
form attacks, headache and vomiting are fairly common. Eye symp- 
toms are frequent, as diminished vision or blindness from initial optic 
hyperemia and subsequent atrophy, strabismus, nystagmus, and wide, 
possibly reactionless, pupils. Other special senses suffer. All the 
limbs, or the legs alone, often present spasticity, contractures, paresis 



1036 DISEASES OF THE XERYOUS SYSTEM 

and increased reflexes, if not secondary degeneration in the pyramidal 
tracts. The face may be similarly affected. The child walks late, if 
at all. Sensation is practically normal. In some instances there is 
constipation, which may be followed by vomiting, diarrhoea, emacia- 
tion and death. Puberty may be delayed or the infantile testes may 
persist. Lumbar puncture shows increased intraspinal pressure, 
amounting to a column of 36 mm. of mercury. 

Complications are largely anomalies of development, as syringo- 
myelia, hydromyelus, meningocele, microcephaly, porencephaly, an- 
encephaly, and encephalocele. 

Course. — The course varies considerably. Some subjects die dur- 
ing or after birth. Many die in the first three years from increase of 
brain pressure with coma, from intercurrent disease or diarrhoea. 
In some cases temporary remissions are seen, and in still rarer in- 
stances, permanent arrest of the process occurs, the mind improves 
with partial recovery, the speech shows some defects or the gait remains 
paretic and spastic. In very exceptional cases, rupture externally is 
observed after head trauma, or spontaneous breaking into the ear or 
nose occurs, as in Lebert's case, which " leaked" for five years. Gall 
reported a case which lived fifty years, and Goelis one of seventy-one 
years' duration. 

Acquired Chronic Hydrocephalus. 

It is difficult and often impossible to differentiate between the 
acquired form and an acute exacerbation of the congenital variety. 

Etiology. — The causes are (a) stasis, either general (cardiac or 
pulmonary) or local (brain tumor or sinus thrombosis); (b) cachectic 
transudation, as in carcinoma or nephritis; and (c) inflammation, 
beginning as acute meningitis of the sporadic or epidemic type, or as 
slowly beginning chronic basal meningitis, especially in young children. 
The same points of obstruction may exist as in the chronic variety. 
(d) Rickets is possibly a cause or at least a frequent associate. 
Quincke's idea that some forms are angioneuritic has been mentioned. 
Some cases show nothing at autopsy. 

Symptoms. — Meningitic symptoms usher in some cases in which 
after weeks or months new evidences of brain pressure appear, as 
alteration in the pulse and breathing, unequal pupils or coma. Head- 
ache, vomiting, vertigo, visual disturbance, spastic paresis, epilepsy, 
altered mentality, idiocy or involvement of the cranial nerves are seen, 
as in the chronic congenital form. The shape of the head, however, 
is not altered. 

Diagnosis of the chronic congenital and acquired forms. — Differen- 
tiation between the two forms is usually very difficult, unless there is 
an accurate history, (a) From rhachitis: The two affections are often 
associated, for some unknown reason. The rhachitic head is square 
rather than globular, it protrudes more in front and laterally than 
behind, the sutures are less widely separated, the fontanelles are wide 



PACHYMENINGITIS 1037 

but do not bulge, and there are no signs of brain tension. The head 
should be measured, because the rhachitic head often seems larger 
than it actually is. (b) From brain tumor: The two conditions are 
sometimes coincident. In each, symptoms of brain pressure, both 
focal and general, are observed. The congenital form is more easily 
distinguished by means of the history of the disease from birth, and 
its slower course, but focal symptoms are less common, as hemiplegia, 
monoplegia, and hemianesthesia, and spinal symptoms are more com- 
mon than in tumor, (c) Hyperostosis of the skull (Paget's disease), 
brain hypertrophy and acromegaly increase the size of the head, but 
they are rare and are separable by the same methods of argument as 
in rhachitis. 

Treatment. — Few therapeutic results can be obtained. Bandaging 
the head is sometimes helpful, but must be carefully done, lest it 
aggravate the brain compression. Puncture of the lateral ventricles 
dates from the time of Hippocrates. Isolated recoveries are recorded, 
but the evacuation must be slow. Permanent drainage is usually 
fatal, but occasionally has resulted in cure. Attempts to obliterate the 
ventricles have recently been made, as in Mikulicz's, Troje's and Leur's 
efforts to effect anastomosis between the ventricles and the subdural 
space; McArthur was successful in three cases. Lumbar puncture 
in acquired forms may be useful; though less dangerous than radical 
measures, death may result. 



DISEASES OF THE CEREBRAL MENINGES. 

Inflammation of the dura is termed pachymeningitis, and inflam- 
mation of the arachnoid and pia is known as leptomeningitis, or simply 
as meningitis. 

PACHYMENINGITIS. 

, External pachymeningitis is essentially a surgical disease and pos- 
sesses no independent significance, being secondary to skull disease 
(syphilis, trauma), various infections and atrophic brain affections. 
Its symptoms are indefinite, as pain, headache, or possibly hemi- 
plegia, or they are those of the primary lesion; the diagnosis is difficult. 
Surgical treatment in Macewen's 22 cases gave 100 per cent, recovery. 
Internal pachymeningitis is divided into (a) the purulent form, which 
follows bone disease or leptomeningitis; and (b) the pseudomem- 
branous type, sometimes with fluid between its layers, which is known 
as serous pachymeningitis and is seen chiefly in general paralysis or 
in children with perisplenitis. These varieties are not as important as 



1038 DISEASES OF THE XERVOUS SYSTEM 

the last variety, known as pachymeningitis hemorrhagica interna; this 
form was described by Heschl (1855), and a year later Virchow gave 
it the present name; he regarded the inflammation as primary and the 
hemorrhage as secondary. Kremiansky (1868) developed the etiology 
and produced the disease in dogs by administration of alcohol. 

Etiology. — (a) Most cases occur in middle and advanced years, 
although a few are seen in marantic children. Fifty percent, occurs 
in persons over fifty years of age, 40 per cent, in those over sixty, and 
25 per cent, in those over seventy (Gowers). (b) Seventy-seven per 
cent, of cases occur in males, (c) Paretic dementia causes 19 per cent. 
Pachymeningitis is common in other dementias and chronic psychoses, 
whence its far greater frequency in asylums and poorhouses than in 
private or hospital practice. It also occurs in senile atrophy, arterio- 
sclerosis, and encephalomalacia. (d) Chronic alcoholism, frequently 
with cardiac and renal disease, is a more frequent cause than the 
statistics of Konig show, viz., 6 per cent, (e) Trauma, as during 
birth, from forceps delivery, or from small pelvis. (/) Hemorrhagic 
diathesis (scurvy, haemophilia, leukaemia, pernicious anaemia), chronic 
nephritis, (g) Infective diseases, as typhoid, scarlatina, puerperal 
fever (9 per cent.), heart disease (18 per cent.), hereditary syphilis 
(11 per cent.), tuberculosis (23 per cent.), bronchitis, and pertussis 
are also causes. 

Pathology and Pathogenesis. — 1. Gross Pathology. — In slight cases 
the inner surface of the dura is cloudy, yellow or brown from 
punctate hemorrhages or haematoidin deposits. In pronounced cases 
the dura shows membranous laminae, which are adherent by prolifer- 
ation of bloodvessels and by organization. The laminae may number 
even 20 and may be a quarter of an inch thick. Those layers nearest 
the brain are the most newly formed. Repeated hemorrhage into the 
layers of the newly formed tissue or between them is very frequent, 
and may be an inch or more thick or may reach the size of an egg. 
The free hemorrhage may spread over the entire surface of the brain, 
even reaching the retina; older foci are apt to be encapsulated. Cyst 
formation in the clot, suppuration and calcification are rare issues. 
The leptomeninges are tinged and often somewhat inflamed. Corres- 
ponding to the most frequent seat of pachymeningitis, the convexity 
of the brain is compressed, especially over the motor areas. The 
process is bilateral in 56 per cent, of cases, and the basal cranial 
nerves are seldom implicated. 

2. Minute Examination. — The normal dura is vascularized from its 
external aspect, and the branches spread into a capillary mesh on its 
inner surface. The fresh fibrin of the earliest hemorrhage and the 
exudation contains red cells with large nuclei, and, nearest the brain, 
a covering of endothelial cells. Later the exuded fibrin develops 
capillaries, organizes, and again hemorrhage occurs from the newly 
formed vessels. This organizes in turn, so that successive laminae 
develop. The older layers become firm and fibrous. 

3. Pathogenesis. — Virchow viewed the affection as primary pachy- 



PACHYMENINGITIS 1039 

meningitis with secondary hemorrhage, but Spierling and Hueguenin 
held that the hemorrhage was primary, with secondary inflammation. 
Virchow's views still hold for most cases, although more recently 
Jores has proven that two classes of cases exist, (a) In traumatic 
cases, the hemorrhage is primary and a simple clot forms which later 
organizes into firm connective tissue; this variety is called regressive. 
The same sequence is thought to occur in cases due to the blood dis- 
eases, acute infections, and arteriosclerosis, (b) In chronic pachy- 
meningitis proper, the inflammation is primary, the process is pro- 
gressive, the connective tissue formed in layers is looser, more vascular, 
and its inner, successively formed layers, are the seat of repeated 
hemorrhages. 

Symptoms. — In most cases there are no symptoms, because the 
membrane is small and the hemorrhage is slight, or because the pachy- 
meningitic symptoms are overshadowed by those of the original dis- 
ease. In the minority of cases, symptoms exist depending on the 
intensity of the process, its extent and localization. 

1. General Symptoms. — The most frequent one is headache, which 
is per se of little differential value. It is diffuse and is most marked 
in alcoholics. Vertigo is also of no diagnostic value. These symp- 
toms increase in value when mental dulness or irritation and coma 
develop with focal signs (v. i.). There may be prodromal delirium. 
The pulse is sometimes slow and irregular. Choked disk is not rare. 
Moderate albuminuria sometimes occurs. The temperature is vari- 
able, but may be slightly elevated. 

2. Focal Signs. — The most important is hemiplegia, which is pre- 
ceded for some time by coma (Furstner). The paralysis is contra- 
lateral, rarely complete, varies with increase or decrease of the clot, 
often involves the cortical facial and hypoglossal centres, is sometimes 
bilateral and is associated with aphasia (33 per cent.), hemihypsesthesia 
(especially involving the muscle sense and therefore causing hemi- 
ataxia), hemiamblyopia, contractures in the paretic members and 
Jacksonian epilepsy. Conjugate deviation of the head and eyes, 
nystagmus and forced postures may be observed. The patient may 
grasp at his clothes, or at his hair or beard (Furstner). The pupil 
contralateral to the lesion is usually larger (Griesinger) ; the pupils 
react poorly, and later both are wide. The tendon reflexes are increased, 
but the skin reflexes are decreased or abolished during the coma. The 
basal nerves are very rarely involved; trismus and rigidity of the neck 
are uncommon. Statistics on lumbar puncture are as yet lacking. 

Course and Prognosis. — Death may occur in the first seizure, or the 
symptoms may subside for months, years, or possibly permanently. 
Residual signs are common and include headache, ataxia, psychical 
alteration, paresis and aphasia. Recurrence is frequent, with stupor, 
coma, and hemiplegia until death occurs (a) from the fundamental 
disease, (b) from the hemorrhage, or (c) from intercurrent affections. 
The outlook depends on the etiology; for instance, it is better in 
alcoholism than in dementia. 



1040 DISEASES OF THE NERVOUS SYSTEM. 

Diagnosis. — A correct diagnosis is rare. A patient with paretic 
dementia may die from a pseudo-apoplectic shock/ or from pachy- 
meningitis, or a nephritic subject may succumb to pachymeningitic 
hemorrhage, uraemia, brain oedema or heart failure. A presumptive 
diagnosis can be made from (a) the age, (b) basal disease (paretic 
dementia, alcoholism), (c) preceding dulness or coma, (d) hemiplegia, 
or (e) irritative phenomena (small pupils and convulsions), (/) from 
variability and (g) recurrence of the symptoms. 

Differentiation. — It should be distinguished from localized brain 
disease as (a) paretic dementia (q.v.), and (b) cerebral hemorrhage. 
Differentiation may be impossible, especially when pachymeningitic 
hemorrhage is very large. The etiology is different, and in pachy- 
meningitis there is more cortical irritation, the coma and paralysis are 
more variable, and temperature, narrow pupils and optic neuritis are 
more common, .(c) In encephalomalacia, the hemiplegia is more often 
attended by aphasia and hemiansesthesia, and there is less cerebral 
irritation, id) Brain tumor is easily distinguished. Trauma, apo- 
plectiform attacks and progression with remissions occur in both affec- 
tions. Tumor usually appears earlier in life, does not depend on 
alcoholism, and focal signs, intense headache, and choked disk are 
much more common. 

Diffuse brain disease chiefly concerns meningitis, whose cardinal 
symptoms (q. v.) and course are usually distinctive. 

Treatment. — Treatment should be (a) prophylactic and etiological; 
and (b) that of the seizure. The use of the ice-cap, quiet, elevation 
of the head, application of leeches back of the ear, and possibly vene- 
section are indicated. Nourishment should be given by rectum. 
Morphine and chloral relieve the headache, excitement or convulsions. 
Lumbar puncture has not proven beneficial (Ricken). Operation was 
first performed by Ceci in traumatic cases and by Annandale, Jaboulai, 
Monroe, and Ballard in other varieties. In the future, surgery will 
probably benefit a larger number of cases. 



MENINGEAL HEMORRHAGE. 

Meningeal apoplexy may be extradural, subdural, arachnoideai 
subarachnoideal, and subpial. 

Etiology and Pathology.— (a) Trauma may rupture the anterior, 
middle or posterior meningeal arteries, with or without fracture of the 
skull. Rupture occurs usually at the site of trauma, but sometimes 
by contre-coup. The corresponding veins may rupture, also the 
sinuses, or the pial vessels from the latter of which blood may percolate 
to the base of the brain, affecting the basal nerves, or may reach the 
spine. The internal carotid may be ruptured, and death then occurs 
precipitately. External hemorrhage is either diffuse or circumscribed 
and results most frequently from middle meningeal rupture. The 
blood clot may weigh 3 to 17 ounces or may reach the size of the 



MENINGITIS, SUPPURATIVE, EPIDEMIC, TUBERCULOUS 1041 

fist, compressing the brain, and dislocating the falx. If the dura is 
injured, blood may be found in its substance. During birth (see In- 
fantile Cerebral Paralysis) trauma may be a factor, and hemor- 
rhage has even occurred during gestation from maternal trauma 
(Teale), but asphyxia and precipitate labor are more important; 
large symmetrical hemorrhage of the convexity is common. (b) 
Arteriosclerosis and rupture of cerebral aneurysms may cause menin- 
geal hemorrhage, (c) Acute infections, hemorrhagic diathesis, sinus 
thrombosis and rarely, heart and lung disease, may produce it. id) 
Ten per cent, of cases occur under ten years and 50 per cent, under 
forty years of age (Gowers). Small clots may be absorbed or micro- 
gyria, porencephalia, cysts or brain sclerosis may result. 

Symptoms. — Clinical latency is not rare in the new-born, possibly 
because of the poor development of the motor centres. Small hemor- 
rhage may in the adult produce no symptoms. Very large ones result 
in early sudden death. In rupture of the middle meningeal artery there 
are (a) symptoms of brain pressure with those of brain concussion or 
contusion, as loss of consciousness, irritative symptoms, increased 
breathing, slowed pulse, pallor, vomiting, and slight fever (100° to 101°). 
Either death or improvement may result. (6) In other cases improve- 
ment from the concussion and contusion occurs; there may be an 
interval of hours to often of days when hemorrhage occurs or recurs, with 
coma, pressure symptoms, mono- or hemiplegia and convulsions as in 
pachymeningitis. Rigidity is rather rare; it is less frequent than in 
meningitis, but Oppenheim has observed rigidity on the hemiplegic side 
and flaccidity on the sound side, which may cause error in localization. 
The pupils are variable. Hemorrhage of the sinuses and pia are said 
to cause monoplegia frequently; the brain nerves are sometimes 
reached by infiltration to the base. In the new-born, there is asphyxia, 
slow then rapid pulse, and coma; this is followed later by epilepsy, 
idiocy and spastic paralyses. 

Differentiation. — From concussion: an exact diagnosis is possible 
only after trephining, or by the clinical evolution. From cerebral 
hemorrhage: the course is very rapid. Differentiation from slow, 
ingravescent cerebral hemorrhage is impossible. 

Prognosis and Treatment. — Ninety per cent, of cases die from 
expectant treatment (Wiesmann); 33 per cent, die in twenty-four 
hours, and, when the hemorrhage is due to aneurysmal rupture, 30 per 
cent, die in ten hours (Lebert). Early surgical treatment is indicated; 
this was especially described by Kronlein. 



ACUTE LEPTOMENINGITIS; SUPPURATIVE, EPIDEMIC AND 
TUBERCULOUS. 

In 1768, Whytt, of Edinburg, noted the acute hydrocephalic symp- 
toms of meningitis but failed to recognize the meningitis, which Quinn 
(1779) described. In 1805, Vieusseux, of Geneva, described the epi- 

66 



1042 DISEASES OF THE XERVOUS SYSTEM 

demic variety; in 1806, it was seen by Danielson and Mann in New 
England, and they performed the first autopsies (Osier). Coindet 
(1817) described the cry, cri hydrencephalique, and Senn in 1825, 
coined the name meningitis. In 1819, Guibert described the granula- 
tions and Guersant spoke of meningite granuleuse as associated with 
phthisis. Parpavoine (1830) recognized the tuberculous form and 
Gerhardt of this country two years later drew the profession's 
attention to the role of tuberculosis. In 1855, Rilliet and Barthez 
distinguished the suppurative, secondary, tuberculous and other 
forms. 

Acute leptomeningitis, or meningitis, is of various forms which may 
well be considered together, because the main symptoms are common 
to all, though epidemic meningitis might be classed under the acute 
infections, and tuberculous meningitis is usually part of a generalized 
tuberculosis. Their contrast is better effected, however, under the 
grouping followed below. 

General Etiology. — 1. Trauma. — The microorganisms of the ear or 
nose may find ready access to the brain, when its resistance is lessened 
by wounds, concussion, or contusion. 

2. Regional Extension. — (a) From the ear: acute or chronic disease 
of the middle ear, antrum or petrous bone may invade the brain 
through the bone, along the lymph or bloodvessels, the nerve sheaths 
or sinuses (see Brain Abscess) and may result in suppurative, tuber- 
culous or serous inflammation, (b) From the nose: extension by this 
route is generally less common, but may be frequent in the epidemic 
form (Weigert). The disease may be acute or chronic, spontaneous 
or operative (by sounding with a probe), syphilitic, tuberculous, men- 
ingococcic, neoplastic or suppurative, of the nasal mucosa or of the 
ethmoidal, sphenoidal or antral cells. Infection may travel through 
the bone, along the veins which communicate with the dura, or along 
the olfactory nerve endings. . (c) From the eye: the avenues to the 
brain are numerous, and yet disease of the eye itself, even panophthal- 
mitis is less important than orbital cellulitis or enucleation, which 
exposes the sheath of the optic nerve, (d) Extension may also result 
from other less frequent sources, as parotitis, carbuncles, especially of 
the face, whose veins communicate with the cavernous sinus; scalp 
affections; erysipelas; bone disease, especially abscess and tubercle; 
and sinus thrombosis. 

3. Metastatic or Secondary Extension. — (a) Tuberculosis is the 
most frequent cause, and this is easily understood when we study the 
statistics of Nageli, who found tuberculosis in 97 per cent, of autopsies. 
(b) Septicopyemia, from lung suppuration, empyema, arthritis, endo- 
carditis and kindred affections; (c) pneumonia (about 0.5 per cent, 
in 5,540 cases); and (d) rarely exanthemata may produce it. In this 
group there is probably an intermediate link, as otitis media in scar- 
latina and empyema or lung infarct in typhoid, (e) Syphilis, generally 
subacute or subchronic may also cause it. 

4. The Epidemic Form. — This is in itself an etiological entity. 



SUPPURATIVE MENINGITIS 1043 

5. Diseases of Metabolism. — Meningitis may rarely occur in the 
course of diabetes, nephritis, gout, arteriosclerosis or malnutrition, but 
it is probably only a terminal infection. 

General Bacteriology. — (a) The tubercle bacillus is the most com- 
mon microorganism, (b) The pneumococcus is probably the most fre- 
quent among the non-tuberculous varieties. It was first found by 
Frankel and simultaneously by Bardoni-UfTreduzzi. This form may 
be primary, or secondary to pneumonia, (c) Pyogenic organisms, 
especially the Streptococcus pyogenes and the Staphylococcus pyogenes 
aureus; (d) the Meningococcus intracellular is (Diplococcus intracellu- 
laris meningitidis) which was found by Marchiafava and Celli, then 
by Weichselbaum (1887), and Jager, and was first withdrawn by 
Heubner by lumbar puncture; and (e) the typhoid bacillus (Roux, 
Adenot, Lenhartz), the colon bacillus (Braun, Chantemesse, Widal, 
Netter), the influenza bacillus (Pfuhl and Hagerstedt), Friedlander's 
pneumobacillus, Bacillus pyogenes foetidus, Bacillus pyocyaneus, pro- 
teus,gonococcus, Bacillus anthracis, Bacterium lactis aerogenes, Bacillus 
aerogenes meningitidis (Cantani), and trypanosoma are also found. 



I. Suppurative Meningitis. 

This is usually a secondary affection. 

Pathology. — 1. Macroscopically a purulent exudate is found between 
the dura and leptomeninges and in the meshes of the arachnoid. The 
dura is tense and its inner surface dry. The leptomeninges are reddish, 
cloudy and are often dotted with punctate hemorrhages. The exudate 
is clearly purulent, yellow or whitish-green, and succulent. The 
infection spreads rapidly, follows the perivascular lymphatics, as 
streaks of pus, imbeds the vessels and nerves in its meshes, obliterates 
the sulci, and involves not only the brain membranes but also those 
of the cord. It is a misapprehension that the epidemic cerebrospinal 
form (v. i.) involves the spinal meninges, and that other suppurative 
forms do not. The brain is always altered; it is succulent, swollen, 
springs out as the membranes are cut, is vascular, and sometimes 
locally anaemic from compression by the exudate; its surface is most 
affected, by such changes as small abscesses, punctate hemorrhages or 
minute islets of softening or encephalitis. The convexity is most 
often involved in the metastatic form (convexity meningitis) and the 
base most frequently in ear disease. There may be primary or second- 
ary sinus thrombosis. The ventricular fluid is often increased, and 
is cloudy, purulent or sometimes serous. The apertures of the ven- 
tricles may be occluded (see Hydrocephalus); inflammation may 
be noted in the velum interpositum, choroid plexus or ependyma. 
In the spinal membranes the changes are similar and are most marked 
over the posterior part of the dorsal region. The process is usually 
diffuse. On incising the membranes, the swollen cord bulges out 



1044 DISEASES OF THE XERYOUS SYSTEM 

and the same changes are seen as in the brain. The process may 
extend along the nerve trunks and bloodvessels, even into the orbit. 

2. Microscopically there are the usual findings of inflammation, 
perivascular exudation of red and white cells, and fibrin formation. 
Vascular dilatation and exudation are seen in those cases in which 
the membranes appear normal to the naked eye. Exudation is most 
marked over the cortex and near the ventricles, but may also occur 
deeper in the medullary substance. The ganglionic cells show degen- 
eration, although they have not been studied systematically. Analo- 
gous findings are present in the cord, on its surface or about the central 
canal. In the optic nerve, exudation, hemorrhage and oedema are 
seen, possibly also in other cerebral and spinal nerves. Various bac- 
teria are found (v.s.), as the pyogenic organisms, the pneumococcus, 
and the meningococcus. Mixed infections are not uncommon. It 
must be remembered that pathologically (though not bacteriologically), 
the suppurative and epidemic forms are identical, and some writers 
still maintain that the epidemic is but a subtype of the suppurative 
variety. 

Symptoms. — Prodromal phenomena are ambiguous and vary with 
the causal disease; otitis, pneumonia or pyaemia may long overshadow 
or totally obscure meningeal manifestations. Complete latency is pos- 
sible, as in a case seen by the author with Dr. Besley; a convalescent 
pneumonia patient, while dining, felt dizzy and died in a few minutes. 
The autopsy revealed a massive, purulent cerebrospinal meningitis, 
which had produced not a single sign or symptom, (a) The onset 
may be sudden with chill and fever. (6) Headache is usually the first 
and most prominent symptom, and is often associated with vomiting. 
(c) The sensorium is disturbed, there is vertigo, and delirium which 
is succeeded by stupor and finally by coma, in wrKch, however, head- 
ache may still be evidenced by the patient holding his head, (d) 
Convulsions may occur; they are particularly equivocal in children. 
(e) Optic neuritis may develop if the course of the disease is not too 
precipitate. (/) Rigidity of the neck and spine is soon noted as well 
as (g) hyperesthesia, hyperalgesia and muscular rigidity, (h) Fever is 
usually present, although in very rare instances (v. s.) it may be absent. 
It is usually higher than in other types, perhaps 104° to 105°, and 
rather more continuous. Toward the end it may be 107° or it may 
even drop to subnormal, (i) The pulse is usually faster and often 
irregular, (j) Irritation and paralysis of the cerebral nerves develop, 
(they are considered more fully under the epidemic form), and are 
manifested by ocular paralysis, nystagmus, strabismus, pupillary 
inequality and tardy reaction to light, facial paresis, grinding of the 
teeth or trismus especially if the inflammation is basal, (k) If the 
process involves the convexity, cortical irritation may be manifested 
by Jacksonian epilepsy and mono- or hemiplegia (which is sometimes 
due to reflex inhibition). (I) Lumbar puncture (see Diagnosis) reveals 
purulent or clear fluid and frequently the organisms of suppuration. 
Increased tension is also observed, (m) Kernig's sign (see Diag- 



EPIDEMIC CEREBROSPIXAL MENINGITIS 1045 

nosis) is present, (n) There may be other symptoms. Constipation 
is usually present. The abdomen is often retracted, there may be 
vomiting, the urine is febrile and frequently contains albumin and 
peptone. The course is generally rapid; it lasts a few hours to more 
usually a few days (two to ten) and almost invariably results fatally 
in coma. The diagnosis, differentiation and treatment are considered 
with the other types. 



II. Epidemic Cerebrospinal Meningitis. 

This form has been definitely recognized only during the last century. 
Though many authorities, as Schultze, Dieulafoy and Netter, deny 
that it is an absolutely independent affection, it is usually described 
as a specific infection involving the cerebrospinal meninges, caused by 
the Diplococcus intracellular is meningitidis and occurring epidemically 
or sporadically. 

Bacteriology. — The meningococcus resembles the pneumococcus 
and gonococcus. It lies in pairs or even tetrads, its contiguous sides 
are flattened, and it resembles two coffee grains with their flat sides 
apposed. It is wider than the pneumococcus and less lanceolate. It 
is usually but not always intracellular, being enclosed in the poly- 
morphonuclear leukocytes. Unlike the pneumococcus, it usually has 
no capsule, although one may develop in serum cultures. It decolorizes 
by Gram's method, although Jager has sometimes observed the con- 
trary. Cultures do not show very active growths ; it develops best on 
agar or blood serum as white, viscid, shining colonies. It grows 
poorly on gelatin. Subcutaneous inoculations are usually negative, 
therein differing from the pneumococcus, but it produces inoculation- 
meningitis, and peritonitis. The meningococcus is found in the nose, 
from which it is thought to invade the brain. Lord found it in the 
nose, in cases with and without meningitis. Goodwin and Scholly 
(1906) isolated the cocci from the nasal mucus in 50 per cent, of 
meningitis patients and in 10 per cent, of those in close contact with 
them. Its presence has been demonstrated in the blood (in 25 per 
cent, of cases, Elser), kidneys, joints, spleen, ear, tonsils, lymphatic 
nodes, pleura, lung, heart valves, pericardium and more rarely in the 
sputum and urine; it probably travels by way of the lymph vessels. 

Predisposing Etiology. — Children and young adults are especially 
predisposed; it occurs more often in males, is apparently more fre- 
quent in the country, although it is often endemic or epidemic in 
barracks, prisons, hospitals and tenements. The disease has closely 
followed the movements of armies or regiments. Though not very 
directly contagious, its contagiousness seems proven beyond question. 
As many as seven members of a family have been successively stricken. 
Most cases are seen in the late winter and early spring; the author 
has always seen some cases in these months. One thousand deaths 
occurred in New York in the first four months of 1905. Trauma, 



1046 DISEASES OF THE XERYOUS SYSTEM 

overwork, and depression are but predisposing causes. Like pneu- 
monia, it often attacks the robust. It may recur; Councilman col- 
lected five instances of recurrence. The disease is also seen in the 
horse and goat. 

Pathology. — The findings in the main are those of the suppurative 
form, viz., those of an acute fibrinopurulent, or less often a sero- 
purulent leptomeningitis. The cerebral dura is seldom, and the spinal 
dura often, involved. The inflammation follows the lymphatics and 
vessels penetrating the brain and cord, resulting in encephalitic or 
myelitic foci, small abscesses, parenchymatous and interstitial changes. 
The axis cylinders are sometimes lost. Flexner and Barker observed 
rows of cells "like miniature tubercles/' of which some were two to 
eight times the size of the leukocytes. The exudate is rich along the 
fissures, fossa of Sylvius and at the base about the chiasm or the 
surface of the pons and cerebellum. Hydrops ventriculorum is fairly 
frequent, in cases of long standing. Some consider that caseation 
may occur as the beginning of resolution and healing. In other organs 
the changes are those of acute infection, the muscles are brownish- 
red, dry and degenerated, there is parenchymatous degeneration in the 
heart and kidneys, and sometimes acute splenic tumor, arthritis, 
pneumonic foci or swollen glands in which (v.s.) the coccus may be 
found. 

Symptoms. — The period of incubation is not definitely known, but 
lasts from a few hours to several days (three to eleven). Prodromes are 
vague, as malaise, or headache. Strumpell and others observed 
initial coryza. The onset may be gradual or sudden, sometimes with 
a chill and usually with fever. In general, the course is febrile, 
attended by brain irritation; by an almost constant triad of symptoms, 
headache, rigid neck and hyperesthesia; by vomiting, mental, motor 
and sensory symptoms, and in most cases death results from paralysis, 
convulsions or coma. 

1. General Nervous Symptoms. — (a) Headache is almost invariable, 
though it is sometimes absent in very young children, in alcoholics 
and in sepsis. It develops early, is most severe and is at first localized 
(frontal or occipital), but soon becomes generalized. Though it varies 
somewhat in intensity, it is constant, with exacerbations, and provokes 
the short, plaintive, clear meningeal cry, cri hydrencephalique (Coindet, 
1817), which is largely heard in children. The headache is throbbing 
or lancinating, even under narcotics, and persists after delirium and 
even coma have set in. Its cause may be compression of the dura, 
changes in the brain, inflammation of the nerve trunks, or ventricular 
exudation. (b) Hyperesthesia or hyperalgesia affects the special 
senses (causing intolerance of light and noise), or general sensation 
(affecting the arms most, the trunk less and the legs least). It is rarely 
absent, is always suggestive, and is probably due to root neuritis, (c) 
Rigidity of the neck and spine is caused by inflammation of the nerve- 
roots, possibly from lesions in the pons or medulla. The head is 
retracted, sometimes so severely that the occiput lies between the 



EPIDEMIC CEREBROSPINAL MENINGITIS 1047 

shoulders, producing decubitus. The entire body may be lifted by 
the head. Swallowing is rendered difficult. Marked opisthotonos may 
be present. Flexion and extension of the head are impossible, although 
lateral movement is sometimes possible. Retraction, although absent 
in exceptional instances, is one of the cardinal triad. Closely associated 
and caused in the same way, is severe spinal pain with tenderness, 
chiefly in the neck and loins, which is felt rather to the side of the 
spine than directly over it. It may radiate to the trunk and in 33 per 
cent, of cases to the extremities, and may affect every muscle, (d) 
Contractures of the limbs are caused by root inflammation, increased 
pressure, or lesions in the pyramidal tracts. Kernig's sign (see Diag- 
nosis) comes under this head, (e) Mental symptoms often occur early, 
especially in children, neurotics and alcoholics; they include unrest, 
insomnia, delirium (sometimes with periods of normal intelligence), 
and mania which is followed by stupor and incomplete coma. (/) 
Vomiting, in the initial stage, is due to vagus irritation; later it results 
from ventricular hydrops or increased cerebrospinal pressure. It is 
of the cerebral type, i. e., it occurs without nausea, without relation to 
eating, is often projectile and is not amenable to gastric therapy. 
Vomiting is more typical and common in children. The tongue may 
later become coated and foul, (g) The pulse at first is increased, and 
is sometimes disproportionately rapid, considering the fever. Some- 
times it slows later because of brain pressure but ultimately it is fast 
again. It may be irregular in rhythm and oscillating in rate. Friis 
noted variation from 84 to 144 within a minute. Qi) Respiration is 
irregular in 20 per cent, of cases; Cheyne-Stokes breathing is not 
common, save toward the end. Deep breathing with apnceic pauses 
(Biot's breathing) is quite common, though less so than in the tuber- 
culous type. (i) Convulsions are most common in the young; they 
may occur at the onset or later. They are important, but ambiguous 
from their frequent occurrence in other diseases of childhood. 

2, Focal Nervous Symptoms. — These are partly irritative and partly 
paralytic, (a) Symptoms relating to the cranial nerves are as follows: 
These nerves are most involved in basal localization, while the limbs 
are most affected in that of the convexity. The optic nerve is fre- 
quently inflamed, if the disease lasts over four days. The disk is 
swollen and its margin is "washed" (see Plate V, Fig. 4). Neuritis 
is less frequent than in tumor; hemorrhage and choking are uncom- 
mon. The ocular muscles may be involved. The pupils at first are 
usually small, often unequal, and sometimes variable like the pulse 
Later they widen spontaneously or on movement of the head, and 
irritation of the skin, but do not react to light. These as well as 
the following changes, result from cortical or basal disease. Ptosis, 
diplopia, nystagmus, and strabismus (spasmodic or paralytic) are 
frequent but often vary from time to time. Complete paralysis of 
the third nerve is not common. Involvement of the fifth nerve is 
unusual, although trismus, grinding of the teeth and trigeminal neural- 
gia have been noted. Involvement of the facial nerve is frequent, 



1048 DISEASES OF THE XERYOUS SYSTEM 

ranking next to that of the third nerve. If diseased at the base, its 
paralysis is usually total; if at the cortex it is of the cerebral type, and 
its upper third escapes. The paralysis varies from time to time (v. s.). 
The facial expression shows suffering, the brows are slightly elevated 
and the forehead is corrugated. The risus sardonicus is not frequent. 
The auditory nerve is often bathed in pus, and hemorrhagic inflam- 
mation in the labyrinth results from extension. The tongue on 
protrusion may deviate to one side ; dysarthria or dysphagia are some- 
times seen, (b) Symptoms relating to the limbs occur as follows: 
Paralysis of the limbs is not very frequent, although Belor noted it 
particularly in one epidemic. Hemiplegia is rarely complete, occurs 
with or without participation of the tongue and face, and is not always 
caused by involvement of the cortex or changes in the pyramidal 
tracts, but sometimes is apparently due to reflex inhibition. It is 
frequently accompanied by rigidity of the limbs and aphasia. It is 
most frequent in children, occurs early or late and may be temporary 
or permanent. Monoplegia is not common and most often concerns 
the face or arm. Choreiform or athetotic movements, twitchings and 
tremor are occasional. Convulsions are frequently Jacksonian in type. 
Sometimes the paralyses are spinal, as shoulder atrophy or paraplegia, 
which also involves the functions of the bladder and rectum. The 
tendon reflexes, as the patellars, may be increased at first and are often 
decreased or abolished late in the disease. The reflexes of the skin 
are variable. 

3. General and Somatic Symptoms. — (a) There is almost always 
fever, though afebrile cases exceptionally occur. The temperature 
rises suddenly, is sometimes very high and although it follows no 
definite cycle, lysis is usual in cases which recover. An inverse form 
is sometimes seen. A temperature of 107° or higher may be registered 
before death, {b) The blood shows leukocytosis, which is early, con- 
stant and of no prognostic import; the white cells may number 
25,000 to 40,000; the meningococcus has been found (v. s.). (c) The 
abdomen is often retracted, and is scaphoid, especially in the iliac 
regions, although less so than in the tuberculous type. It may be 
due to retraction of the abdominal walls, but Traube gave the best 
explanation, namely that the intestines are tonically retracted from 
irritation of the vagus, which also causes the constipation, (d) The 
spleen is often palpable, (e) The urine is febrile, albuminous (33 per 
cent.) and may show peptonuria, hematuria (in malignant cases), and 
rarely glycosuria or polyuria (Traube). (/) The nutrition suffers, 
which Leube explains as due to cerebral influences, (g) As to the 
skin: the tdche cerebrate described by Trousseau has no differen- 
tiating value, for it occurs in many febrile and other conditions. 
Eruptions are more common in the epidemic than the sporadic cases, 
and vary with the individual epidemic. Herpes (40 to 75 or even 90 
per cent.) varies with the epidemic; it is most frequent on the face, 
but may develop anywhere; it spreads more rapidly than in any 
other disease (v. Ziemssen); in one case the author saw it extend 



TUBERCULOUS MENINGITIS 1049 

from the lip to the ear, neck, chest and shoulder. Purpura, which 
gave the name "spotted fever" to the disease, occurs in the more severe 
types. Other eruptions, as erythema, roseola, urticaria or gangrene 
are uncommon. (See General Diagnosis for lumbar puncture.) 

Clinical Forms. — Hirsch distinguishes (a) the acute or subacute type, 
the ordinary form in which the acute symptoms of onset are followed 
by the general nervous symptoms enumerated, then by focal nervous 
symptoms, somatic symptoms, death in coma, or slow recovery; (6) 
the foudroyant form, with violent onset, rapid course and death in a 
few hours (three to thirty-six) with apoplectic symptoms, or purpura, 
high fever, irregular heart and early coma; (c) the abortive form, with 
low fever and symptoms so mild that the disease is recognized only 
by its association with an epidemic ; the ambulatory type is included 
here; and (d) Heubner's chronic form, which lasts several (two to six) 
months, w T ith marasmus, and recurrent fever. 

Complications. — These vary with the epidemic. Pneumonia, bron- 
chitis, tonsillitis, pleurisy, parotitis, endo- and pericarditis, arthritis 
(J. Jackson, Sr.) and nephritis are the most common. Pneumonia 
may be due to the pneumococcus, but the meningococcus has been 
found in small isolated foci in the lung (Councilman). The arthritis 
is either poly- or mono-articular, simple or suppurative, and may heal 
even when suppurative; it occurred in 25 per cent, of Flexner's and 
Barker's series. 

Sequelae. — Mental alteration, paralysis, contractures, obstinate 
headache, optic atrophy, deafness or Meniere's syndrome may remain 
after recovery. Chronic hydrocephalus, paroxysmal headache, vomit- 
ing, pains, and convulsions (v. Ziemssen) may result. In an epidemic 
in Heidelberg, Moos found as sequels deaf -mutism in 60 per cent., 
absolute deafness in 31 per cent, and an atactic gait in 50 per cent, 
of the cases. 

Prognosis. — The average mortality is 30 to 40 percent. (37 per cent., 
Hirsch in 15,632 cases), but varies with the epidemic, and may reach 
75 per cent. Fifty per cent, of the deaths occur in the first five days. 
Recovery is exceptional, although possible, after deep coma, repeated 
convulsions, high fever or paralysis of the vagus. Obstinate vomiting, 
disturbed respiration, sudden drop of temperature and inanition are 
ominous signs. 

III. Tuberculous Meningitis. 

Etiology. — Most cases occur between the second and tenth year, 
some cases develop in adolescence, and few late in life ; at least three 
times as many cases occur in children as in adults. Tuberculosis in 
children is usually generalized, and miliary tuberculosis is in 80 per 
cent, associated with meningeal disease. Tuberculous meningitis is 
almost always secondary, and follows pulmonary or glandular tuber- 
culosis, less frequently joint disease, genito-urinary, brain tubercle and 
other localizations. Extension bv contiguity from the nose, eve, or 



1050 DISEASES OF THE XERYOUS SYSTEM 

spinal cord is possible. Strtimpell and Leube believe that infection 
may creep from the pleura, along the nerve sheaths to the spinal 
cord, whence it reaches the brain. Heredity is clearly a factor in some 
cases. Measles, whooping-cough, typhoid or pneumonia may be the 
proximal cause, for the virus of the disease seemingly arouses latent 
glandular or other tuberculous foci. Trauma is not a frequent cause 
but is of distinct clinical and medico-legal importance. In the case 
of a baggage man thrown upon his occiput by the sudden stopping of 
the train, an acute tuberculous meningitis developed, which resulted 
in death in three weeks. The autopsy disclosed an apical focus, from 
which the bacilli infected the injured brain. In a case seen with Dr. 
J. H. Hess, the affection immediately followed an ansesthetic (given 
to examine a tender spine), and was fatal within a week. 

Pathology. — The diagnosis is made macroscopically in the majority 
of cases, although in some instances the changes are slight. The 
exudate is gray, yellow or green, gelatinous, sticky, purulent or serous, 
and covers the base (basilar meningitis) from the chiasm to the medulla. 
Tiny tubercles are found on the basal nerves and deep in the fissure 
along the Sylvian artery where "they look like lice eggs on a hair." 
Careful search is sometimes necessary for their detection. They are 
most clearly seen in the translucent arachnoid, and on superficial 
examination look like minute air bubbles. They are seen quite fre- 
quently over the convexity and may cause adhesions between the two 
hemispheres. The ventricular fluid is increased in 80 per cent, of 
cases, and usually measures a few ounces; tubercles and inflammation 
of the ependyma are not uncommon; the external and internal com- 
munications of the ventricles may be obliterated. The substance of 
the brain shows the same changes as in other forms, as ischemic or 
encephalitic softening or sometimes large tubercles. The cerebrospinal 
fluid is usually increased and is clear or cloudy. In the cord the 
exudate may be a quarter of an inch in thickness, and is largely dis- 
posed over the posterior part of cord because of the patient's dorsal 
decubitus. The cord membranes are almost regularly affected, and 
sometimes appear granular, as "though sown with fine sand." Tuber- 
cles in the substance of the cord are not considered common, but 
Wartmann found them in 87 per cent, of his cases. The cranial and 
spinal nerve sheaths are pyriform and bulging. Microscopically , 
exudation is found as in the other forms above described. The nodes 
are proven to be tubercles; bacilli are found in them and in the 
cerebrospinal fluid. The microscope differentiates between tuber- 
culous inflammation and tuberculosis of the meninges (without inflam- 
mation), and again in some cases proves the existence of tuberculous 
meningitis not visible to the naked eye. Neuritis of the cranial and 
spinal nerves is constant. The optic, oculomotor and facial nerves are 
the most often affected. In the cortex, base and ependyma of the brain, 
the usual histopathology of tubercle is seen, with tuberculous endar- 
teritis from mural inflammation (Hektoen), and periarteritis, small 
encephalitic and myelitic foci in practically every case, vessel throm- 



TUBERCULOUS MENINGITIS 1051 

bosis, swelling of the neuroglia and degeneration of the nerve cells 
and of the lateral columns, especially of the axis cylinders. 

Symptoms. — Prodromes are more prominent in children than in 
adults. Fever, emaciation and anaemia are due to preexisting lung or 
glandular tuberculosis. Irritability, change in disposition, tendency to 
cry, inability in children to play or in adults to work, unrest, insomnia, 
headache, nausea and constipation may develop in a week or two or 
in one to three months. Trauma, measles, and pertussis may be the 
apparent cause. The outbreak develops with much the same symp- 
toms as those described under the epidemic form, but they appear 
more gradually, so that the classical description comprises three stages: 
(a) The stage of irritation, with headache, vomiting, remittent fever 
reaching 102° in the evening, the cri hydrencephalique of Coindet, 
night terrors, pain and rigidity in the neck and spine, small irregular 
pupils, delirium, grinding of the teeth, hyperesthesia, rigidity of the 
limbs and Kernig's sign; (b) the stage of brain pressure, with paralytic 
and irritative conditions in the eye muscles, as ptosis or strabismus; 
with paralysis of other cranial nerves or of the extremities, as mono- 
plegia, especially of the face, or hemiplegia from involvement of the 
cortex, and very frequently aphasia and dulness; with general or 
Jacksonian convulsions, slow, irregular and quite variable pulse; 
retracted abdomen, constipation, continued vomiting; sighing respi- 
ration; and very frequently with optic neuritis; and (c) the stage 
of paralysis, in which the vomiting and often the headache cease, 
the sensorium is dulled, absolute coma develops, the pulse becomes 
rapid and vacillates in rate and rhythm. Biot's or Cheyne-Stokes 
breathing appears, emaciation is extreme, the pupils are wide and 
immobile, the eyeballs roll upward, and a typhoid state with dry 
tongue or abdominal distention exists. Temporary remissions of days, 
weeks, or even a year are occasional in which the pulse remains 
irregular, but the patient lapses again into coma, the fever rises very 
high (107°) or falls low (even to 93°), and death occurs in several 
weeks from cardiac or respiratory failure, dysphagia, inanition or 
hypostasis. This division into stages is not wholly satisfactory, 
because the symptoms of one stage may merge into those of another 
but the progression of symptoms is somewhat as described. 

Tubercles in the choroid were first found anatomically by Autenrieth 
(1808), and Gueneau de Mussy (1837), and clinically by Jager, 
Manz, and Busch; they are rare clinically, being found by Garlick 
in 4 per cent, and Kramer in 13.6 per cent, of cases. Heinzell did 
not find them in 41 cases. At postmortem examination Litten found 
them in about 75 per cent. (See Plate VI.) Leukocytosis is usually 
absent, unless it occurs during the agony or from mixed infection. 
The spleen is enlarged in 33 per cent, of cases. 

Many variations exist. The process may be wholly latent, being 
masked by miliary tuberculosis (or meningeal symptoms may dominate 
when the greatest pathological changes are in the lungs). Coma may 
be sudden and the disease may run a short course, resembling apoplexy. 



1052 DISEASES OF THE XERYOUS SYSTEM 

especially in adults; in these cases the hemiplegia probably results 
from changes in the arteries. It may appear to be a psychosis. In 
adults the course is more rapid, the headache and delirium more 
marked and the convexity more frequently involved than in children. 
Death is usual, but rare recoveries are recorded by Waterhouse, Ord, 
Leube, Fiirbringer, Dujardin-Beaumetz, Freyhan, Rilliet and Barthez, 
Jansen, Carrington, Hensch, Politzer, and lately by Gross, even after 
bacilli were found by lumbar puncture or after choroidal tubercles 
were demonstrated. 

IV. Serous Meningitis. 

This is more frequently seen at the bedside than at the autopsy. 
It is often tuberculous. The inflammation is slight, the membranes 
are glistening, clear or flocculent fluid is seen in the arachnoid meshes 
and ventricles, which may be the sole seat of the disease, and the pia 
especially shows exudation. It is often mistaken for oedema of the 
brain. The microscope may be necessary to demonstrate inflamma- 
tion, which frequently is circumscribed. The process sometimes occurs 
with encephalitis, poliomyelitis, Landry's ascending paralysis, typhoid 
or pneumonia. 

Symptoms. — In the serous (non-suppurative and non-tuberculous) 
form, no definite symptoms can be outlined. The disease certainly 
exists, although it is relatively infrequent, but with equal certainty 
it is too frequently diagnosticated. Headache is common; vomiting, 
rigidity, fever, slow and labile pulse, optic neuritis, hyperesthesia, 
spasms, and paralysis of the cerebral nerves are much less frequent 
than in the other forms of meningitis though they are occasionally 
observed. The symptoms resemble those of brain tumor. Lumbar 
puncture in some instances has given absolute relief; the prognosis 
is most favorable in this type. 

General Diagnosis of Meningitis. — The first step is the diagnosis of 
meningitis, which in general has an acute or subacute onset, with 
signs at first of general, then local inflammation of the surface of the 
brain. The second step is determination of the variety (suppurative, 
epidemic, tuberculous, primary or secondary), or the cause, and the 
locality (convexity or base). 

Cardinal Symptoms. — The early triad of (a) headache, (6) retraction 
and rigidity of neck and (c) hyperesthesia, is important and develops 
early, (d) Other general symptoms, as causeless vomiting, abdominal 
retraction, pulse and respiratory changes, fever or convulsions, are 
important in their grouping, (e) Lumbar puncture (Quincke, 1890) 
is of diagnostic value. Its technique is as follows: The patient lies 
on the side with the knees drawn up and the body bent as far forward 
as spinal rigidity allows; with or without chloroform, an aspirating 
needle or small trocar is introduced in the median line in children, 
and a quarter to half an inch to one side in adults, between the third 
and fourth lumbar vertebrae (Quincke) or between the last lumbar 



DIAGX0S1S OF MEXIXGITIS 



1053 



Fig. 62. 



vertebra and sacrum (Chipault), and is pushed forward toward the 
median line and a little upward, one and a half inches (2J cm.) deep 
in children and 1.5 to 2.5 inches (4 to 6 cm.) in adults, until it passes 
into the canal. Fiirbringer prefers to have the patient in the sitting 
posture. Not more than 4 to 5 drams (15 to 20 cm.) should be with- 
drawn, lest fatal results ensue. Negative taps result from needle 
occlusion by clots. Results: (i) normally, the pressure with the patient 
in the lateral position, equals 100 to 150 mm. of water and the escap- 
ing fluid only trickles out. In meningitis, the pressure is greatly in- 
creased (200 to 700 mm.) and the fluid often spurts out. (ii) The 
normal fluid is clear, has a specific gravity of 1,007-09 and contains 
little albumin (-J- to 1 pro mille). Though the fluid may be clear in all 
forms of meningitis, it is usually clear in the serous form, but cloudy, 
flocculent or sometimes bloody in other forms; in the tuberculous 
variety it is usually clear or slightly yellow with a whitish clot forming 
on standing; in the epidemic form, it may be turbid or clear, with a 
yellowish clot (Netter) ; in the purulent type it is opaque, and in rare 
cases it is pure pus. The specific gravity is about 1,010 in the serous, 
1,011 in tuberculous, and 1,015 in purulent or epidemic variety, al- 
though these figures are not absolute. The percentage of albumin is small 
in the serous, 2 pro mille in tuberculous, and 3 or even 8 or 9 pro mille in 
the suppurative forms, (iii) Bacteriologically (see Bacteriology) in 
the purulent type the strep- 
tococcus, staphylococcus, 
pneumococcus, typhoid and 
colon bacilli are found; in 
the epidemic variety, the men- 
ingococcus, which was posi- 
tive in 100 per cent, in the 
last New York epidemic, is 
present; in the tuberculous 
type, tubercle bacilli exist in 
66 percent, of cases as an aver- 
age (73 per cent. Bernheim 
and Mosler, 81 per cent. Fiir- 
bringer, and 100 per cent. 
Holtzmann); even in this 
form, mixed infection with 
the pus organisms and men- 
ingococcus may be seen; the 
tubercle bacilli are often found 
on cover slip preparations; 
cultures grow too slowly for 
clinical diagnostic value, (iv) 
The cellular morphology (cyto- 
diagnosis) is a valuable aid. 

In the purulent and epidemic form the leukocytes are largely polymor- 
phonuclear; in the tuberculous form the lymphocytes predominate. 




Kernig's sign, showing retraction of head and back and 
prominence of knees in the erect posture, i. e., the im- 
possibility of extension of knees. (Dieulafoy.) 



1054 



DISEASES OF THE NERVOUS SYSTEM 



according to Widal, Sicard, and Rivault (see Cytodiagnosis, 
Pleurisy) ; some dissension exists on this point, as well as on the 
statement that iodine given by mouth is found in the tuberculous 
and not in the purulent (epidemic) exudate. 

(/) Kernig (St. Petersburg, 1882), described a sign known as Ker- 
nig's sign. When the patient sits, it is impossible (in 75 to 95 per cent, 
of all meningitis cases) to extend the knees, as shown in Fig. 62. 
The legs and thighs are flexed (flexor contracture) and the knees 
cannot be pressed down, i. e., cannot be extended when the patient is 
sitting but this is possible when he is lying. It indicates that the 
spinal meninges are involved. It lasts well into convalescence, whence 
as Netter states, " a retrospective diagnosis may be made. " It occurs at 
times in subdural hemorrhage, sinus thrombosis, encephalitis, and 
cerebellar tumor. It is sometimes unilateral. It may possibly indicate 
degeneration of the pyramidal tracts. 

(g) Local signs usually follow the general signs, and are more impor- 
tant. They include the pupillary changes, strabismus, facial paralysis, 
and hemiplegia. Often their late development lessens their value for 
early diagnosis. 





Epidemic Form. 


Tuberculous. 


Suppurative. 


Onset : 


Sudden, with few pro- 
dromes. 


Longer prodromes; 
family history; 
other evidences of 
tuberculosis. 


Sometimes primary 
but oftenest 
secondary to ear 
disease, acute in- 
fections, trauma, 
pneumonia. 


Fever : 


Fairly high. 


Less; inversed type 
frequently; some- 
times absent. 


Especially high, with 
chills, perhaps 
pyaemic type. 


Eruptions : 


Herpes and purpura 
very common. 


Rare. 


Rare — polymorphous 
septic rashes. 


Leukocytosis: 


Regular and marked. 


Exceptional. 


Frequent. 


Rigidity of neck : 


Most frequent. 


Spinal symptoms 
somewhat less fre- 
quent. 


Sometimes absent 
(pneumococcic 
form). 


Other symptoms: 


Peptonuria. 


Choroidal tubercles. 


Peptonuria. 


Course : 


Rapid — more recov- 
eries. 


Subacute, slower, 
fatal. 


More acute, very 
rarely recover. 


Lumbar puncture: 


Meningococcus; 
leukocytes poly- 
nuclear. 


Tubercle bacilli; 
mononuclear. 


Pyogenic cocci, 
pneumococcus; 
polynuclear. 



Diagnosis of the Variety. — This is more difficult. Cases of tuber- 
culous meningitis sometimes increase when the epidemic form prevails, 
and the meningococcus may be found in these cases (Heubner, Len- 



DIAGXOSIS OF MENINGITIS 1055 

harz, Netter). Sporadic cases, due to the meningococcus, may be 
indistinguishable from primary pneumococcic meningitis, save by 
lumbar puncture. 

Diagnosis of Location. — (a) Localization on the convexity results 
from trauma, or metastatic infection; it is characterized by more fre- 
quent delirium, Jacksonian convulsions, mono- or hemiplegia, less 
cranial nerve paralysis and less optic neuritis. (6) Localization at the 
base results from the tuberculous form, chronic nephritis, cachectic- 
states, and the non-tuberculous forms which occur in childhood ; it is 
characterized by more frequent cranial neuritis, and optic neuritis. 
(c) The ventricular form rarely involves the cranial nerves. 

Differentiation. — 1. From nervous toxsemic symptoms, as those of 
typhoid (q. v.). Jenner pointed out that in acute infections the head- 
ache ceases when delirium begins. This is also true of the pseudo- 
meningeal symptoms of pneumonia, typhoid, sepsis, etc. Some cases 
with focal symptoms are most confusing (see Uraemia), but the albu- 
minuric retinitis, the cardiovascular changes, and albuminuria, casts, 
and deficient elimination are usually sufficient for distinction. Acute 
inflammation of the labyrinth may resemble meningitis, for it sometimes 
produces headache, vomiting, fever, convulsions, stiff neck, and even 
optic neuritis. If labyrinthitis involves the meninges, the facial nerve 
is likely to be affected. Such conditions resembling meningitis, Dupre 
(1894) called meningismus, and Bouchut (1895) pseudomeningitis. 

2. From Brain Disease. — Syphilitic meningitis (q.v.), brain abscess 
(q. v.), cerebral hemorrhage (q.v.), and encephalitis (q.v.), have been 
considered. Great difficulty is sometimes experienced in differentiat- 
ing between slow tuberculous meningitis and tumors of the brain, as 
tubercle of the pons, or rapidly growing glioma. A moderately severe 
optic neuritis may suggest tumor or meningitis; intense neuritis, with 
choking, swelling and hemorrhage is indicative of tumor. Paralysis 
is more sudden in meningitis than in tumor. 

3. From Hydrencephaloid (see Brain Anaemia). — 4. Hysteria is 
marked by its usual stigmata, viz., psychical alteration, limitation of the 
field of vision, anaesthesia and other stigmata. Hysterical strabismus is 
always spastic and convergent, and is often associated with small 
pupils; meningitic strabismus is often divergent (always a sign of 
organic disease), and the pupils are unequal. 

Treatment. — Prophylaxis and treatment of the causal disease are 
indicated. The patient should be kept quiet in a dark room, the 
head elevated without flexion, an ice-bag applied to the head and 
spine/or an ice-pillow should be used. Nutrition should be maintained 
by feeding with the nasal tube or by nutrient enemata, if retraction of 
the neck causes dysphagia. The bowels should be mildly relaxed, and 
the bladder should be watched. Vomiting is treated as in acute gastritis 
(q.v.), but therapy is usually unavailing, for the cause is cerebral irrita- 
tion; of drugs the bromides are customarily most servicable. Feeding 
by the rectum, sucking of ice, and the remedies indicated for the head- 
ache give the greatest relief. Counterirritation by blisters and the 



1056 DISEASES OF THE NERVOUS SYSTEM 

use of the cautery are dangerous because the skin sloughs readily. 
Headache, restlessness and convulsions necessitate the use of opiates, 
though theoretically opium congests the brain and its membranes. 
The hypodermic use of morphine, or the use of the deodorized tincture 
of opium by mouth, is necessary, and free from harm; no other analgesic 
is equally potent. Ergot should relieve the congestion, but it never 
replaces the opiates. Atropine reinforces the analgesic action of opium. 
Chloral is used chiefly for the convulsions and for unrest. Warm baths 
were first recommended by Aufrecht and Waroschilsky, and in the epi- 
demic type are considered almost specific by Netter. Stimulation is 
indicated when the heart weakens, and coma is imminent, until which 
time alcohol should be withheld. Resorbents, as iodides, are of little 
value, (although Niemeyer recommended them). Mercurial inunctions 
are regarded as inefficacious, although milder types of meningitis, as the 
serous form, are apparently benefited. 

Lumbar puncture can permanently relieve only the simple or serous 
forms. Its repeated use may induce punctate hemorrhages, although 
sudden death is much less likely to occur from its use than in uraemia 
or brain tumor; isolated cases of recovery in the pneumococcic and 
tuberculous forms have followed repeated puncture. Surgery is indi- 
cated in circumscribed rather than in diffuse meningitis. Macewen, 
Jaboulay, Greave, Gluck, Joel, and Barker, have operated with, as a 
rule, no remarkable results. Macewen saved all of six cases of sup- 
purative cerebral meningitis, and one of six cerebrospinal cases. 
Ventricular puncture, first recommended by Wernicke, in 1883, 
lapsed into disuse and was needlessly revived by Horsley, Paget, 
Rickett, von Beck, and Bennirighous. Diphtheria antitoxin has been 
used (Wolff), but its exact benefit is still uncertain. 



CHRONIC LEPTOMENINGITIS. 

Etiology. — (a) It may result from acute leptomeningitis, (b) The 
leptomeninges thicken after trauma, in atrophic and sclerosing brain 
disease, as paretic dementia, hydrocephalus, and softening, and in 
alcoholism, gout, nephritis, or plumbism. (c) Chronic productive 
inflammation occurs in syphilis, tuberculosis and suppuration. 

Pathology and Symptoms. — The leptomeninges are diffusely or 
locally dense, thick, opaque and microscopically show fibrous tissue. 
In the chronic tuberculous form, the membranes are thick, fibrous, 
and caseous; they compress the cortex, especially the psychomotor 
areas, and produce generalized and Jacksonian convulsions, headache, 
monoplegia, aphasia, and mental changes. It may sometimes heal. 
In the chronic suppurative form, the pus loculi are situated in a firm, 
fibrous tissue. The symptoms, if cortical, are like those of the chronic 
tuberculous form; if basal, nerve paralysis and optic neuritis are com- 
mon. In the chronic simple form (Gee and Barlow) the process may begin 
acutely and may persist, especially at the base and in the posterior 



DISEASES OF THE SPINAL CORD 1057 

fossa. Possibly it is a sequel of a localized epidemic type (this theory 
was rather favored by Koplik in a recent paper), or of hereditary 
syphilis, trauma, or otitis. It is seen especially in children ("simple 
meningitis of children"); 76 per cent, of cases occur in the first year 
of life. Rigid neck is the leading symptom, though convulsions and 
rigidity of the extremities do occur. Paralyses are rare. Fifty per cent, 
of patients die. The alcoholic form is slight, diffuse and cortical ; men- 
ingitic symptoms are obscured by alcoholic disease of the liver, kidneys, 
heart or peripheral nerves. Headache is little developed; there is 
moderate delirium and slight optic neuritis. Diagnosis is difficult, 
and therapy is wholly etiological. 



DISEASES OF THE SPINAL CORD. 

(A). GENERAL ANATOMICAL, PHYSIOLOGICAL, AND SYMPTOM- 
ATIC CONSIDERATIONS. 

The nervous system is made up of numerous similarly constituted 
units, called neurones (Waldeyer). Each neurone comprises (a) a 
central nerve cell; (b) protoplasmic processes or dendrites from the cell 
which conduct (cellulipital) impulses to the cell; (c) an axis cylinder 
or axone arising from the cell and conducting impulses (cellulifugal) 
from the cell; and (d) the terminal ramifications of the axis cylinder, also 
known as end brushes or arborizations. The axis cylinder often gives 
off lateral branches, known as collaterals or paraxones. The nutrition 
of the nerve cell probably depends upon the integrity of its nucleus, and 
the nutrition of the cell governs that of its neurone. Disease of the 
cell causes degeneration of the entire neurone ; division of a process or 
axis cylinder results in its degeneration below the point of separation 
from the nutrient cell. It is still uncertain whether the neurones are 
wholly independent of each other, although most authorities favor 
this view. At times, and especially in the retina, some degree of anas- 
tomosis between the dendrites of different systems exists (Dogiel). 
The nerve cells are closely grouped in the gray cortex, gray substance 
of the cord and in the ganglia of the peripheral nerves. The axis 
cylinders largely course through their white substance. To compre- 
hend the most important point in spinal diseases, the localization, we 
must recognize that pathological processes are in general of two varie- 
ties: (a) those involving certain neurones, or system diseases, as tabes, 
and (b) those not involving given tracts or neurones, or the non- 
system diseases. 

The functions of the cord are (1) conduction of motor impulses to 
the muscles; (2) conduction of sensory impressions to the brain; (3) 



1058 



DISEASES OF THE XERVOUS SYSTEM 



certain reflexes; (4) centres governing the bladder, rectum, etc., and 
(5) trophic influences. 

1. The motor tract is composed of two sets of neurones or segments. 
The upper segment has its origin in the cells of the motor cortex (A Fig. 
63), and runs through the white substance, i. e., the corona radiata, 
internal capsule, crus, pons, and in the anterior pyramids of the medulla 



Fig. 63. 



LEG AND ARM 




Illustrating the course of the two motor neurones: A, cortical cell of origin of motor tract; B, de- 
cussation in medulla; C, course in lateral columns of cord: DD, branches to anterior horns in 
cord; in second (lower) neurone, E, cells of anterior horns; E", cells in pons; F, nerve trunks; 
G, motor end plates; H. muscles. 



(whence the name pyramidal tracts), it crosses to the opposite side, (B 
Fig. 63), running down in the lateral columns of the cord (C) and 
giving off branches (DD) to the anterior horns, where the tract ends in 
fine terminal filaments, which surround the motor ganglion cells in the 
anterior horn. (For the general course of the upper motor neurones, 
see Fig. 56). The lower segment begins with the motor cell in the 
anterior horn (E), the dendrites of which are in contact with the ter- 



LOCALIZATION IN THE SPINAL CORD 



1059 



minal ramifications of the axis cylinder of the upper segment by con- 
tact (Ramon y Cajal) or by concrescence (Held) ; it extends along its 
own axis cylinder into the anterior nerve roots and nerve (F), and ends 
in terminal ramifications (G) (motor end plates) in a muscle of the 



Fig. 64. 




GANGLION CELL OF 

CORTEX. BEGINNING 

OF 1ST NEURONE 



TERMINAL FILAMENTS 
END OF FIRST NEURONE 



GANGLION CELL OF ANT. HORN 
BEGINNING OF 2ND NEURONE 



-END OF 2ND NEURONE 
IN MUSCLE PLATES 



Illustrating the general outlines of the upper and lower neurones and of the direct (DPT), and 
crossed (CPT) , pyramidal tracts. 



arm or leg, which is on the side opposite to the origin of the cortical 
motor centre. From the cells of both segments the motor impulse 
travels downward from the cell (cellulifugal conduction). About 75 
per cent, of the upper motor neurones cross as above described, are 
called the crossed pyramidal tracts (C. P. T. in Figs. 63 and 64), and lie 
in the lateral columns of the cord. Twenty-five per cent, of the motor 
fibers (rarely 40, even 90 or 100 per cent., Zenner), do not cross (decus- 
sate) in the medulla, but pass down in the anterior columns of the same side 
and are called the anterior or direct pyramidal tracts (D. P. T. in Figs. 
63 and 64). The anterior direct pyramidal tract usually ends in the mid- 
dorsal region, but if small may reach only to the cervical enlargement 
of the cord, or if large may even reach the fourth or fifth sacral nerves. 
This tract probably crosses to the anterior horn of the opposite side 
by way of the white portion of the commissure of the cord. There are 
probably some other motor tracts in the cord. The upper segment is 



1060 



DISEASES OF THE NERVOUS SYSTEM 



largely (75 per cent.) crossed, but the lower segment (or neurone) is a 
direct tract, the cells in the anterior horns supplying muscles of the 
same side of the body. 

The cord, therefore, contains parts of both neurones, the course of 
which has been ascertained by the secondary descending degeneration 
which follows neurone lesions. Morgagni, Cruveilhier, and Rokitansky 
noted some atrophy in the cord after brain lesions which destroyed the 
motor paths, but Tiirck first fully described its occurrence and Bou- 
chard, and Barth confirmed his findings. Flechsig, and later Bech- 
terew added information from embryological studies. After a lesion, 
as hemorrhage in the internal capsule, the fibers of the upper neurone 
below the lesion show signs of degeneration. In a few days granule- 
bearing cells appear and somewhat later the axis cylinders swell, 
degenerate and stain poorly, especially when studied by the Marchi 



Fig. 65. 







i wmmm 



f-, l-t, , .\ O w K-;:---:;t/. ...;-.\/'J ii-^.j; ■:■„% 

m fMm 





Showing the different tracts of the cord. (Gowers.) 

method. These changes occur because the axones are separated from 
the nutrient cortical cells. The neuroglia tissue increases and corpora 
amylacea develop. Degeneration is seen in the opposite lateral pyra- 
midal tracts, and in the anterior column on the same side as the brain 
lesion. Sometimes slight degeneration occurs in the lateral pyramidal 
tracts of the same side (Pitres, Hadden, Sherrington), which probably 
have some connection with the anterior uncrossed pyramidal tract 
of the same side (see Broadbent's theory under Chronic Symptoms of 
Brain Hemorrhage). Since the vitality of the neurone fibers decreases 
as their distance from their trophic cell increases, the degeneration 
is greatest in the most peripheral part of the axone. The degenera- 
tion usually stops at the end ramifications of the axone (see Excep- 
tions, under Brain Hemorrhage, Pathology). (Some fibers lying 
between the direct pyramidal tract and the direct cerebellar tract degen- 




PLATE XVI. 



B 



C 




v% 










A. Ascending degeneration in the posteromedian column and anterolateral ascending tracts from 
lumbar lesion. (After Gowers.) 

B. Ascending degeneration after injury to cauda. (After Schultze.) 

C. Descending degeneration of pyramidal tracts from right-sided cerebral hemorrhage. (After Mott.) 



LOCALIZATION IN THE SPINAL CORD 



1061 



Fig. 66. 



C 1. 



>v 






\ 



1 D 



erate downward; possibly they are part of the lateral pyramidal 

tract [from Deiter's nucleus in the medulla, Russel]. Fibers lying just 

anterior to the lateral pyramidal tract also 

degenerate downward [from the posterior 

corpora quadrigemina, Boyce, and Sakow- 

itsch]. Schultze describes a comma-shaped 

descending degeneration in the anterior 

third of Burdach's column). See Plate 

XVI. 

Degeneration in the Lower Segment. — 
Disease of the anterior horns, division or 
disease of the nerve trunk, causes degener- 
ation of the nerve toward the periphery 
and trophic muscle changes. The degen- 
erated nerve responds neither to the faradic, 
nor to the galvanic current. The muscle 
does not answer to the faradic current, but 
to the galvanic; it answers slowly instead 
of sharply (as is the case with the nor- 
mal muscle). These differences constitute 
the reaction of degeneration (see Neuritis). 
After amputation, the motor nerves and 
anterior roots concerned, waste (Berard, 
1829) very slowly because of lack of func- 
tion, or because of peripheral irritation. 

The two neurones do not correspond in 
number, because one neurone of the upper 
segment is connected with several lower 
neurones, i.e., various cells in the anterior 
horns at different levels are probably ex- 
cited by a single pyramidal fiber. For 
complex movements, as of the hands, 
there are more pyramidal fibers than for 
simple movements, as of the intercostal 
muscles. The anterior spinal root nerves 
join with fibers from the posterior roots, 
and passing downward, leave the spinal 
cord between the vertebrse, thus form- 
ing the spinal nerves, whose area of origin 
in the cord is called a segment. The peri- 
pheral nerves often arise from several seg- 
ments, which are sometimes considerably 
separated; muscles with similar function 
have similar spinal localization, because 
movements rather than muscles are localized ^L 

in the cord, as well as in the brain. The 
appended table gives the localization of the D ; a f. ram f fro ^<^^°^ T 

rr © iV ^ lation of vertebral spines to their 

muscles, with special regard to their cells bodies and to the nerve-roots. 



12 



1 L 



Co 



1062 



DISEASES OF THE XERVOUS SYSTEM 






Segment. 



Muscles. 



Skin: Sensation. 



Reflexes. 



2-3 Cervical 



4 Cervical 



5 Cervical. 



6 Cervical. 



7 Cervical. 



8 Cervical. 



1 Dorsal. 



2-12 Dorsal. 



1 Lumbar. 



2 Lumbar. 



3 Lumbar. 



4 Lumbar. 



5 Lumbar. 



1-2 Sacral. 



3-5 Sacral. 



Sterno-cl-mastoid, trape- 
zius, scaleni, neck mus- 
cles. Diaphragm (3, 4, 5, 
6 cerv.). 

Lev. ang. scapulse, rhom- 
boideus, supra- and in- 
fra-spinatus, deltoid, sup- 
inator longus, biceps. 

Supinator brevis, serrat, 
mag, clavicular portion 
of pectoralis maj., teres 
minor. 



Pronators, coraco-brachi- 
alis, brachialis ant. , tri 
ceps, long extensors of 
hand and fingers. Lower 
neck muscles and middle 
part trapezius, 6,7,8, C 
and 1 D. 

Costal portion of pectoralis 
ma j . , la tissimus d orsi , 
teres maj. 

Long flexors of the hand 
and fingers. 



Extens. poll. long, et brev 
Small muscles of hand 



Muscles of back (also low- 
est part of trapezius) and 
abdomen. Intercostals 
D, 1-10. 



Abdominal muscles, quad- 
ratus lumborum. Ileo- 
psoas. 

Sartorius (or third lumbar), 
flexors of hip. Quadri- 
ceps femoris (extensors 
of knee), cremaster. 

Internal rotators of thigh. 



Adductors of hip, 
Sartorius (?), 
Abductors of hip, 
Tibialis anticus, 
Calf muscles, 

Flexors of knee ( ?) , gluteals 
(extensors of hip). 

External rotators of hip, 
Flexors of foot (?), 
Extensors of toes. 
Peronei. 

Flexors of foot and toes. 
Small muscles of foot. 



Muscles of perineum. 



Neck and occiput. 



Shoulder (anterior part 
Dana). 



Radial side of arm (volar 
and dorsal surface) to 
the insertion of deltoid 
Post, surface of shoulder? 



Dorsal and volar surface of 
radial side of hand to 
midline of middle finger, 
and up to base of hand 
narrow strip on volar and 
dorsal surface up to axil- 
la, connecting with above 
area. 

Ulnar part of hand (dorsal 
and volar) from middle 
of the fourth to middle of 
third finger and connect 
ing with it, a moderate 
strip on volar and dorsal 
surface of arm. 

Dorsal and volar surface of 
hand to middle of fourth 
finger, narrow strip on 
dorsal and volar surface 
of arm up to axilla. 

Narrow strip on ulnar sur- 
face arm and forearm 
down to base of hand 
(The upper part, per- 
haps, belongs to the sec- 
ond dorsal segment.) 

Chest, back, abdomen and 
upper gluteal region. 
(Umbilicus, tenth dor- 
sal : ensiform, sixth to 
seventh dorsal). 



Pubic area, anterior aspect 
of scrotum. 



Anterior and inner side 
of hip, inner side leg to 
malleolus, inner side 
of foot, external sur- 
face of hip, lumbar re- 
gions. 

Posterior surface of hip, 
thigh, external surface 
of leg and foot. 

Back of foot. 



"j Skin of sacrum, anus, 
perineum, genitalia. 



Sudden inspiration by 
sharp pressure below the 
ribs. 



Widening of pupil from 
irritation of neck, 4-7 cer- 
vical. 



Scapular reflex (fifth cerv. 
to first dorsal). Tendon 
reflexes of this group of 
muscles. 



Tendon reflexes of muscles 
named. 



Volar reflex of hand, peri- 
osteal reflexes of radius 
and ulna. Tendon re- 
flexes of muscles named. 



Corresponding tendon re- 
flexes. 



Tendon reflexes. 



Abdominal reflex. Epi- 
gastric reflex (according 
to Dinkier, the epigastric 
is at the ninth dorsal, the 
middle and lower ab- 
dominal at the tenth and 
twelfth, respectively.) 

Cremasteric reflex (1-3 
lumbar). 



Patellar reflex (2-4 lum- 
bar). Erection (lumbar 
cord). Uterus (lumbar 
cord). 



Gluteal reflex (4-5 lum- 
bar). 



Plantar reflex; ejacula- 
tion (3-4 sacral). 

Achilles tendon reflex. 

Bladder and rectum reflex. 



The brackets to the left concern only the muscles, and indicate the origin of the muscles from 
several nuclei. 



PLATE XVII 




Scheme of Sensory Conduction. (Strumpell.) 

A. Entrance of posterior sensory roots into lumbar cord: g.i., intervertebral ganglion: r.p.. 
posterior root; part of the fibers end in the posterior horns, from whose cells other fibers arise and enter 
the lateral columns, partly on the same and partly on the opposite side; other fibers from the posterior 
roots, course upward in the posterior columns and form in — 

B. (the cervical cord), Goll's columns (G); B.C., Burdach's columns. 

C. Medulla oblongata, G and B are the nuclei wherein Goll's and Burdach's columns end. From 
these, new fibers arise which decussate and form the fillet (lemniscus, L) in — 

D. L, lemniscus; Py, pyramidal tract; O, the olive; c.r., corpus restiforme. 

E. Pons; IV, fourth ventricle. 

F. L, lemniscus of fillet ; n.r., nucleus ruber; Py, pyramidal tract in crus cerebri; N.L., 
nucleus lenticularis; T.H., optic thalamus (beginning of new neurone to oortex?). 



LOCALIZATION IN THE SPINAL CORD 1063 

(the beginning of the second neurone) as well as of the skin and 
reflexes. The cord is shorter than the spinal canal, reaching only to 
the second lumbar vertebra. The nerve roots descend, and therefore 
their level at the point of exit does not correspond with their level 
of origin. Fig. 66 shows this relation. 

Table giving localization of function in the various spinal segments 
(from Edinger, Starr, von Leyden, Remak, Thoburn, Ferrier, Yeo, 
Gowers, and Kocher) will be found on page 1062. 

2. The sensory tract conducts upward and is more complicated and 
less clearly understood than the motor tract, because the interpreta- 
tion of experiments made on animals is frequently confusing. It is 
composed of three or more neurones. The cells of the first neurone 
are in the intervertebral ganglia, whose cells end in an axis cylinder 
dividing into a branch to the skin, and another to the cord by the pos- 
terior root. These ganglia are the homologues of those of the vagus, 
or trigeminus (q. v.). Embryologically studied, it would seem less 
likely that the axis cylinder of the ganglion cell divided than that the 
branches from the skin (the peripheral sensory nerves) represented 
the protoplasmic process or dendrites of the ganglion cells ? and the 
branch to the cord represented the axis cylinder. However, all periph- 
eral sensory fibers originate in the ganglia, and almost all fibers of 
the posterior nerve roots come from these ganglia. From the posterior 
roots the fibers reach the cord, where (a) some pass into the posterior 
column, (6) some into the gray matter, and (c) others run to the cells 
of the anterior horns, and are clearly part of reflex arcs. 

(a) The fibers entering the white substance (the posterior columns) 
divide into a short descending branch (which probably is concerned 
in reflex processes, giving off some collaterals and ending in the gray 
matter), and into a long ascending branch, which is the more important 
one ; they enter the posterior column obliquely and by the entrance of 
new fibers at higher levels become more centrally located in the column 
of Goll (posterior median column) in which the lowest fibers (e. g., the 
sciatic), are most posterior and the highest (e. g., the cervical) are 
most anterior. The posterior columns convey fibers for muscle sense 
(sense of posture and movement association) and possibly also for 
simple tactile sensation. "Sensations we do not feel" travel in these 
columns (Gowers). The posterior median (Goll's) column ends in 
the nucleus gracilis of Goll (or postero-median nucleus) in the medulla. 
It is uncrossed, i. e., direct. The posterior external (Burdach's) 
column ends in the nucleus cuneatus of Burdach (or posterior external 
nucleus) in the medulla. It is likewise uncrossed or direct. The first 
neurone ends in these nuclei. The second neurone crosses above the 
motor decussation in the medulla (interior arcuate fibers) to the opposite 
side and unites with fibers that have already crossed in the cord, thus 
forming the fillet (see below, 6). This neurone is crossed. The pos- 
terior nuclei communicate with the opposite cerebral cortex, with the 
cerebellum of the same and opposite side and with the external arcuate 
fibers. 



1064 DISEASES OF THE XERVOUS SYSTEM 

(b) The fibers entering the gray matter of the 'posterior horns also divide 
into ascending and descending branches. Some lie at the zona ter- 
minalis, the most posterior part (Lissauer's zone) of the posterior horn. 
All these fibers end with terminal ramifications about ganglion cells 
in the gray matter; they form the beginning of a second neurone which 
crosses in the commissure of the cord and courses upward in the 
antero-lateral column and anterior ground fibers of the opposite side 
(just anterior to the lateral pyramidal tracts), and they unite in the 
medulla with the fibers of the second neurone of (a) (v. s.). (See Plate 
XVII. The fibers entering the posterior horn convey temperature 
and pain conduction, and travel between the posterior median column 
and the central canal. Tactile sensation is probably conveyed in 
the antero-lateral column. Gowers holds that the antero-lateral 
columns convey most of the upward sensory impulses, since their 
division causes anaesthesia. Both (a) and (b) then run in the median 
lemniscus of the fillet, and in part of the longitudinal bundles of the 
formatio reticularis of the pons, tegmentum of the crus and posterior 
limb of the internal capsule, beyond which their course is somewhat 
uncertain. Some fibers run directly to the motor cortex or back of it to 
the parietal lobes, while others end in the optic thalamus, whence per- 
haps they are connected by a third neurone coursing to the cortex. 

The sensory tracts degenerate upward (ascending degeneration). 
Plate XVI Fig. A shows degeneration in the posterior and antero- 
lateral columns. Most ascending degenerations stop in the medulla. 
The direct cerebellar tract, which begins at the first lumbar nerve, 
also degenerates upward. It increases somewhat in size as it rises 
because of reception of additional fibers, but most of its fibers come 
from the lower dorsal and first lumbar nerves; some of them come 
from the gray substance of Clark's columns to which collaterals are 
sent from the posterior fibers; its function is uncertain, though Flechsig 
believes that it conveys muscular impressions from the lower part of 
the trunk and the legs; its destination is the middle lobe of the cere- 
bellum by way of the restiform body; some fibers then cross to the 
opposite lobe. 

The spinal sensory nerves descend lower than do the corresponding 
motor nerves, and skin sensation for a given area is often supplied 
by two, three, or more nerves, whence anaesthesia results only when 
all of them are diseased (Sherrington). See Wichmann's plate, Plate 
XVIII. 

Lesions of the conns medullaris down to the fourth sacral nerve 
produce paralysis of the bladder and rectum, and saddle-shaped anaes- 
thesia on the anus, gluteal region, perineum, genitalia, under surface 
of the thigh (pudendal and coccygeal plexus) but the scrotum escapes 
because the spermatic plexus and external spermatic nerve connect 
with the lumbar plexus. The cremaster reflex is normal. In Bern- 
hardt's case, sexual desire and erection were preserved, while ejacula- 
tion was incomplete. 



PLATE XVIII. 




4d"'"7 
5d 



7d 






S^H/f 



3] 






i.r /./ 



5 s 



I , 



2 s 



These figures have been devised by Wichmann in order to show the distribution of the sensory areas 
corresponding to the segments of the spinal cord. The colors used correspond to those of the normal spec- 
trum, red, orange, yellow, green, blue, indigo, and violet, with brown; respectively- the first, second, third, 
fourth, etc., segments in each portion of the spinal cord- -cervical, dorsal, lumbar, and sacral. The last four 
segments in the dorsal region are left white. The advantage of the plate is that it shows very clearly the 
overlapping of the segments that has been demonstrated by Sherrington. The dark heavy black lines 
on the arms indicate the division between the two sides of innervation that from the upper portion of 
the cervical enlargement and that from the lower portion. The heavy black lines of the legs indicate the 
divisions between the sacral and lumbar areas of innervation. The figures and letters indicate the seg- 
ments in which the supply lias been drawn ami have been introduced for the sake of making the diagram 
more available for ready reference. C— cervical, D— dorsal, L lumbar, and S- sacral. The horizontal 
bands of color without dividing lines between them indicate that both segments innervate the areas 
involved. (Musser.) 



LOCALIZATION IN THE SPINAL CORD 



1065 



Lesions of the cauda equina (where the roots lie closely together) 
are usually symmetrical. In its upper part, the above symptoms with 
paralysis of both legs are noted; paraplegia dolorosa is frequent 



Fig. 67. 



Fig. 68. 




Lesion at the level of the second lumbar segment 
(Strumpell and Muller, from whom also follow- 
ing figures are borrowed) . 



Lesion at third lumbar segment. 



Fig. 69. 



Fig. 70 




Lesion at fifth lumbar segment. 



Lesion at first sacral segment. 



(See Plate XVI, Fig. B). A lesion below the third lumbar vertebra 
is usually limited to the pudendal and sciatic distribution. Von Leyden 
holds that there is no certain distinction between cauda and conns 



1066 



DISEASES OF THE NERVOUS SYSTEM 



lesions, unless external signs exist, as trauma, tumor or caries, or per- 
haps absence of the reaction of degeneration or the occurrence of 
fibrillary contractions (Strumpell and Schultze). Paraplegia dolorosa 
is rare in pure lesions of the conus, while it is common in those of the 



Fig. 71. 



Fig. 72. 




Lesion at second sacral segment. 



Lesion at third sacral segment. 



Fig. 73. 




Lesion at fourth sacral segment. 



cauda. In conus lesions there may be partial or dissociated anaes- 
thesia (Schlesinger and Higier) which never develops in affections of 
the cauda. 



LOCALIZATION IN THE SPINAL CORD 1067 

3. In the gray matter there are reflex centres which are enumerated 
and localized in the table given above. The reflex arcs comprise the 
afferent sensory fiber with its termination in the gray matter and the 
motor nucleus with its efferent motor fiber. Collaterals probably 
connect the centres at different levels. Hutchinson first suggested 
that the fibers of the oculopupillary reflex ran by way of the sym- 
pathetic nerve (rami communicantes) to the cord. Irritation of its 
centre produces dilatation of the pupil (mydriasis), especially in spina 
caries. Paralysis from disease of the centre produces myosis, narrow- 
ing of the eye fissure, sometimes retraction of the eyeball, and less 
often flattening of the cheek; Madame Klumpke-Dejerine found that 
this paralysis was produced by section of the eighth cervical and first 
dorsal segments; i. e., the localization is the same as for paralysis 
of the forearm and anaesthesia of the ulnar surface of the hand and 
arm. It occurs more often in disease of the nerve roots than in dis- 
ease of the cord itself. The tendon reflexes will be considered under 
the individual cord diseases. They are inhibited from the brain and 
probably also from the cord. Evacuation of the bladder and rectum 
is partly a reflex and partly a voluntary process. There are muscular 
fibers to evacuate the organs and sphincters to retain their contents. 
The former are stimulated by distention and the latter relax; they 
are controlled normally by the will. If inhibition fails, the bladder 
or rectum is evacuated, sometimes with the knowledge of the patient, 
as in disease of the pyramidal tracts, or at other times unconsciously, 
as in coma or when the sensory nerves of the parts are diseased. When 
the lumbar centre itself is affected, there is continuous evacuation. 
As to the rectum, Gowers discovered that disease of the centre dis- 
closes itself by relaxation of the sphincter on digital examination; 
disease above the centre, by normal tonicity of the sphincter. 

From the above considerations, the leading points are given regard- 
ing the level of the lesion and the course of the chief systems. Total 
transverse disease of the cord produces paralysis of the muscles at and 
below that level, and sensory interruption. From these symptoms 
the upper level of the lesion is determined, but it might be difficult 
to decide whether the cord were affected through a narrow horizontal 
level, or whether all the cord, below it, were diseased, unless the reflexes 
below were noted. Hyperesthesia usually discloses the level of the 
lesion. Lesions of the pyramidal tract (first neurone) produce motor 
paralysis at the level of the lesion, increased reflexes and spasticity 
(hypertonic muscular rigidity) but with no muscular atrophy, reaction 
of degeneration or sensory disturbance. In lesions of the posterior 
columns, the chief alteration is sensory disturbance, especially in the 
muscle sense, and therefore incoordination or ataxia. The reflex arc 
may be interrupted. Lesions of the anterior horns or anterior roots 
produce a flaccid paralysis followed by atrophy and the reaction of 
degeneration if the process is acute. (If it is chronic, the atrophy is 
more marked than the paralysis, and the reaction of degeneration is 
absent or atypical. The trophic cells are not specialized in the horn , 



1068 DISEASES OF THE XERYOUS SYSTEM 

but all cells are probably trophic.) The motor nerve (Nasse, 1839) 
and the muscle degenerate; the reflexes are abolished; the muscle 
tension (myotatic irritability) is lost, there is vasomotor paralysis (since 
the fine fibers of the anterior roots are vasomotor), and contractures 
result (from sensory irritation, Goldscheider). If the lesion is in the 
anterior horn, there may be fibrillary muscular contractions. Irrita- 
tion of the anterior horns may increase the reflexes and induce con- 
tractures. In lesions of the posterior horns, there is disturbance of the 
temperature and pain sense and some alteration of the tactile sense; 
the reflexes may be disturbed. (Some maintain that vasomotor symp- 
toms occur). In lesions of the posterior roots, the reflexes are disturbed, 
there is anaesthesia and therefore ataxia. Irritation of these roots 
causes pain, hyperesthesia in the form of a girdle sensation in the 
trunk or lancinating pains in the extremities and reflex contractures. 
The importance of the spinal ganglion as the trophic centre must be 
remembered (Waller, 1852), although Vejas and Joseph declare that 
some fibers pass directly through the ganglion without connecting 
with it. Vasomotor fibers leave the cord through the anterior roots, by 
the rami communicantes, and course down either in the lateral columns, 
or in the intermediolateral tract (Gaskell) from the vasomotor centre 
in the medulla. Most of the vasoconstrictor fibers leave the cord 
between the third dorsal and second lumbar segments, while the vaso- 
dilator fibers are much more diffusely scattered through the cord. 



(B). DISEASES OF THE VERTEBRAE; FRACTURE, DISLOCATION, 
TUMOR, AND COMPRESSION OF THE CORD. 

I. Fracture of the Vertebrae. 

Its incidence is rare, for it constitutes but J of 1 per cent, of all 
fractures (Gurlt). 

Etiology. — Fracture in the dorsal and lumbar regions occurs mostly 
(66 per cent.) in the vertebral bodies, while in the cervical region the 
processes are often (50 per cent.) fractured. Falls, sudden flexion, or 
blows are the most common causes, though in rare cases it is caused 
by simple muscular exertion. Previous disease, caries and tabes may 
favor fracture. Corresponding to the obvious angle in the spine, the 
upper portion usually slips downward and forward, crushing, com- 
pressing or even severing the cord, while the dura is rarely ruptured, 
although the abundant epidural plexus of veins ruptures and forms 
a hematoma back of the cord. Gurlt found fracture most often in 
the fifth and sixth cervical, the last dorsal and first lumbar vertebrae. 
The cord is the seat of hemorrhagic softening or later of inflammation 
(myelitis), which sometimes develops without cord compression. 
Marked or permanent injury results in ascending and descending 
degeneration. 



FRACTURE OF THE V ERIE BR. F 1069 

Symptoms. — They may be (a) local i.e., direct. Dislocation with 
deformity (in 68 per cent.) is the most frequent sign; pain is frequent; 
crepitation (in 38 per cent.) is uncommon save when the processes 
are fractured; its elicitation should not be attempted, (b) General 
symptoms include those of shock and concussion, (c) Spinal symp- 
toms are more or less complete paraplegia (in 71 per cent.), i. e., paral- 
ysis of both arms, legs, or of parts below the lesion. The reflexes are 
decreased as a result of the shock; in complete division of the cord, 
the patellars are totally abolished, even when their lumbar centre is 
not implicated, as in cervical fracture (Bastian, Bruns, Bowlby); the 
reason is not clear; Jackson held that the cause was withdrawal of 
the cerebellar influence; others have suggested that shock or irritation 
was causative; the abruptness of the lesion is certainly a factor, 
since the patellars are present in slow compression (Gerhardt). The 
paralysis may be unilateral (see Brown-Sequard's Paralysis under 
Trauma of the Cord). Sensation is less involved, but radiating pains 
into the extremities may occur when the lesion is at the cervical or 
lumbar enlargement; they are sometimes associated with muscular 
spasm. Continuous erection (priapism) is almost constant, especially 
in cervical fracture, and ejaculation occurs at the time of the lesion. 
Paralysis of the bladder and rectum is usual. The bladder can often 
be emptied by suprapubic pressure. Meteorism may result. Decubitus 
(bed-sores) is common. 

Fracture of the first and second cervical vertebras usually results in 
sudden death; most cases result from caries (Bergmann). Some 
subjects die in a few days, while in a few instances recovery is possible. 
The author has seen two cases with deformity in the spine and pharynx 
without any sign of cord compression. There is pain in the neck, 
pain on movement, fixation of the head, often palpable deformity 
in the pharynx, dysphagia, dyspnoea, vomiting, and paralysis of the 
tongue, palate and of all the limbs, usually with preservation of the 
reflexes. The temperature may reach 111°. The pulse is often slowed 
(to 40 or 20) by paralysis of the accelerator fibers of the heart which 
run from the medulla by way of the lateral columns to the fourth to 
ninth dorsal anterior roots and cardiac plexus. Their irritation may 
produce paroxysmal tachycardia. Fracture of the third and fourth 
cervical vertebrae. Involvement of the phrenic nerve results in respira- 
tory paralysis and early death. In fracture of the fourth cervical to 
second dorsal vertebrae, paraplegia, which increases after the injury 
from hemorrhage, is the chief symptom. In the arms it is often some- 
what asymmetrical. Atrophy may follow injury to the cervical en- 
largement. Pains, hyperalgesia and tonic or clonic spasms in the 
arms are frequent. Anaesthesia is usually less marked than the paral- 
ysis. The intercostal muscles being paralyzed, the patient breathes 
with the diaphragm and the accessory respiratory muscles of the neck. 
Vasomotor manifestations may occur in the pupils, face, trunk or 
extremities. In fracture of the third to twelfth dorsal vertebrae, para- 
plegia, anaesthesia and often paralysis of the bowel and bladder 



1070 DISEASES OF THE XERVOUS SYSTEM 

result. The temperature is often low in lesions of the lower cord. 
Lumbar fracture, except in the first lumbar vertebra, is infrequent. 
Paralysis is not a frequent result, unless there is marked dislocation 
when paraplegia, especially in the peronei, and atrophy, pains in the 
legs along the sciatic and femoral nerves, and anaesthesia occur (v. s., 
Lesions of the Conus and Cauda). 

Diagnosis. — The diagnosis is based on the trauma, symptoms 
shown by the cord, and deformity which, though sometimes absent, 
serves for differentiation from spinal concussion. In doubtful cases, 
the examination for tender points, fixation of the spine and radiating 
pains must be made most carefully, lest the cord injury be thereby 
increased. 

Course. — Healing is difficult, uncertain and incomplete, because 
callus formation is rarer than cartilaginous and fibrous union, and 
dislocation may occur after the trauma. Early death frequently 
results from fractures in the higher vertebrae while in those lower 
down a later death is likely to occur from cystitis, decubitus or sepsis. 
The prognosis is most favorable in fractures between the third dorsal 
and second lumbar vertebrae (Gurlt). According to Burrell — from 
whose collation of 244 cases (1905) most of the above statistics are 
taken, — the average mortality is 65 per cent.; the mortality is 86 per 
cent, in cervical, 76 per cent, in upper dorsal, 56 per cent, in lower 
dorsal and 50 per cent, in lumbar fractures. 

Treatment. — Surgical interference is not indicated in fresh cases, 
unless a comminuted process may press on the cord. If paralysis 
persists from pressure of a process on the cord, especially in the lumbar 
region, operation is indicated. 



II. Dislocation of the Vertebrae. 

Dislocation is traumatic, or spontaneous from previous vertebral 
disease. Traumatic luxation is sudden, injures the cord to a greater 
extent and results from falls or blows on the head or neck. Fracture 
very frequently accompanies dislocation. Luxation from previous 
vertebral disease is gradual, though sometimes sudden, and injures 
the cord less, since it is often incomplete (subluxation). It occurs 
most often in the cervical region, especially in the first and second, or 
fifth and sixth vertebrae. It is infrequent elsewhere in the spine. The 
vertebrae sometimes are torn apart without actual displacement. 

Symptoms. — The head is often bent forward toward the sternum or 
shoulder, very rarely backward. Movement is suspended or limited. 
Tenderness and pain are elicited and the local deformity may be felt 
or even seen. The cord is injured by direct compression, contusion, 
hemorrhage and later by myelitis, with much the same symptoms as 
in fracture. Sometimes no spinal symptoms are observed. Sudden 
death is very common in the higher dislocations from pressure on the 
medulla. 



CARIES OF THE VERTEBRAE 1071 

Treatment. — Reduction is indicated even when the cord is not 
injured, and may relieve all symptoms. 

III. Caries of the Vertebrae. 

Etiology and Pathology. — Pott's disease (Pott, 1779), spondylar- 
throcace, is the most common vertebral disease involving the cord. 
Caries is almost always tuberculous. It is most common after the 
fourth year and in adolescence, but may be seen at any age. Tuber- 
culosis in other organs is frequent in Pott's disease; it usually begins 
"spontaneously," in one or several vertebral bodies or more rarely in 
the articulations. It may follow trauma. The spongy portion of the 
vertebral body is first involved. Granulation tissue is the earliest 
finding; later caseation occurs with extension to contiguous parts, 
the connective tissue, ligaments, processes and cartilage. The collapse 
of the altered body usually produces an angle and prominence in the 
spine called Pott's boss, and the diseased body slips backward, some- 
times compressing the cord. By extension the nerve roots may be 
involved; they are bathed in pus, sometimes show connective tissue 
induration and, in cases of long standing, atrophy. The outer surface 
of the dura is very frequently inflamed (peripachymeningitis or pachy- 
meningitis externa); collections of thick, caseous pus gather in the 
cellular tissue between the dura and the posterior surface of the body 
of the vertebra; the cord is more injured by caseous or purulent 
pachymeningitis than by deformity of the spine. It was once thought 
that the cord was not only compressed but also inflamed, whence the 
name, compression myelitis. 

Compression paralysis (so-called compression myelitis) may result 
from (a) vertebral disease, tuberculosis, cancer, or exostoses; (b) 
disease of the spinal cord and its membranes, as tumors, pachy- 
meningitis hypertrophica, syringomyelia, or hydromyelia; (c) com- 
pression by aneurysm, or echinococcus. Pathologists differ as to the 
actual changes in the compressed cord. Myelitis may develop in 
some cases, according to the older pathology (a) from compression by 
bone fragments or exudate, or acute extension by contiguity of the 
inflammation to the cord; (6) from slower inflammatory reaction, 
following degeneration of the nervous structures, or (c) rarely, from 
tuberculous myelitis. " Compression myelitis" is probably nearly 
always softening (myelomalacia). (Edema of the cord results from 
mechanical lymph stasis in the dura (Kahler and Schmaus) and 
suspends but does not necessarily destroy its functions. Anaemia of 
the cord (Ziegler) is of less importance. Vessel thrombosis may cause 
softening. In some cases with marked paralysis, the postmortem 
examination shows no changes in the cord, whence it is certain that 
pressure may interrupt nerve impulses without structural cord disease. 
In other cases all gradations of alteration are found, from a few granule 
bearing cells or swollen axis cylinders to marked disintegration, corpora 
amylacea, neuroglia overgrowth and induration. 



1072 DISEASES OF THE XERYOUS SYSTEM 

Symptoms. — The symptoms usually develop in the order of group- 
ing given below. 

1. Spinal Column. — Angular deformity (kyphosis, gibbus, Pott's 
boss) is common but not invariable; it is most marked in upper 
dorsal disease, and is at times accentuated by periosteal induration. 
Quite frequently there is only lateral deviation (scoliosis) in which 
connection it must be remembered that ordinary lateral curvature 

,of the spine practically never affects the cord or its nerve roots. 
Local tenderness over or beside the affected vertebrae and pain are 
usually localized and develop early. The application of heat, which 
is not felt over the normal vertebrae, may cause pain over the 
diseased focus (Copeland). Pain and tenderness are very common 
in the neuroses, but the hyperalgesia is largely cutaneous, is usually 
diffuse, and varies more than in caries. Rigidity of the spine is most 
conspicuous in disease of the cervical or lumbar regions, where move- 
ment is normally most free; it is usually an effort to spare pain. 
Gravitation abscesses are fairly frequent and follow along the planes 
of least resistance in the tissues. Dysphagia from retropharyngeal 
abscess or low compression of the oesophagus may cause errors in 
diagnosis. 

2. Nerve Roots. — Eccentric pain is usually the earliest symptom; 
it radiates into the trunk or extremities and indicates involvement 
by pachymeningitis of the posterior nerve roots. It is much less acute 
than in cancer and is especially elicited by movement. Sensory are 
more common than motor root symptoms, and irritative symptoms, as 
hyperesthesia, are more common than anaesthesia. Root symptoms 
are most pronounced in lumbar and sacral disease, and least pro- 
nounced in dorsal disease. 

3. Spinal Cord. — Compression (a) interrupts function at its level, 
disturbs reflexes, impairs rectal and vesical evacuation and (b) inter- 
rupts upward and downward cordal conduction, producing spastic 
paresis or paralysis, anaesthesia affecting all varieties of sensation, 
and increase of skin and tendon reflexes, whereas root disease 
does not interrupt conduction. Cord symptoms develop slowly; 
Oppenheim placed the average time at one year; weakness of the 
legs is followed by paresis, this in time by paraplegia, which, however, 
may develop suddenly. Anaesthesia and other sensory manifestations 
are less common than are motor symptoms, because the sensory 
tracts are more resistant or more protected, since the greatest com- 
pression is exerted on the outer lateral surface of the cord. Ataxia is 
usually obscured by the paralysis. Marked anaesthesia, paralysis and 
atrophy are usually correctly referred to the cord rather than to the 
more resistant nerve roots. The reflexes are increased (unless their 
arc is destroyed at the level of the lesion) since cerebral inhibition is 
interrupted; Sternberg and Sherrington believe there is also a spinal 
inhibition. 

Special Localization. — 1. Dorsal Caries. — This is the most frequent 
type. Gradual deformity is usual, with formation of a sharp or obtuse 



CARIES OF THE VERTEBRAE 1073 

angle. Acute deformity, such as might result from a fall or lifting a 
heavy burden, is much less common. Paraplegia develops in varying 
degrees of intensity with increased muscle tonus (spasticity), increased 
leg reflexes, or even clonus, or paralysis of the bladder and rectum; 
it sometimes develops with contractures but rarely with marked sensory 
changes, other than intercostal root pains in the chest wall, which 
sometimes produce precordial oppression or a girdle sensation. 
Herpes zoster may develop. The level of the lesion may be marked 
by a zone of hyperesthesia or hyperalgesia. Trophic changes in the 
skin are common, as glossiness, smoothness or dryness. There is no 
essential atrophy save from disuse, nor is there any reaction of degen- 
eration, unless the anterior horns are diseased. In cases of partial 
paralysis, the tendon of the tibialis anticus becomes prominent (tibialis 
phenomenon). The tendon reflexes may be increased, even when the 
paralysis is apparently flaccid. They are almost always increased 
below the lesion. Exaggeration of the patellars is an early symptom, 
often antedating the paralysis. The skin reflexes below the lesion are 
often increased, but may be decreased in cases of severe compression, 
though they are seldom absent. The Babinsky reflex (see Brain 
Hemorrhage) is often found. 

2. Cervical and Upper Dorsal Caries. — This form ranks next in 
frequency; radiating pains reach the shoulder, arm and hand, and 
may be felt in or about the joints on one or both sides. Anaesthesia 
is more common, along the ulnar nerve, over the sternum and scapula, 
because the posterior roots are more often affected. Paralysis may 
result from compression of the cord, or from disease of the anterior 
roots, and involves the small muscles of the hand, forearm and triceps. 
The fore-finger and thumb often cannot be apposed (the ape hand), 
and from atrophy of the interossei, the main en grijfe (v. i.) results. 
The forearms are flexed and pronated, while the arms are adducted 
(Thoburn). The tendon reflexes usually persist. In other cases, 
marked atrophy occurs instead of paralysis and the reaction of degen- 
eration sometimes develops. Spastic para-paresis or -plegia in the 
legs from compression of the pyramidal tracts usually accompanies 
the diplegia (paraplegia) brachialis, which, however, sometimes occurs 
alone, when the anterior horns or roots are diseased. Myosis is com- 
mon from injury to the oculospinal centre (Rollet, 1864), and there 
may be narrowing of the eye fissure and less often retraction of the 
eyeball, which is more frequently unilateral than bilateral, or differs 
in degree on the two sides. Flattening and reddening of the cheek 
are less common. These are less symptoms of disease of the cord 
than of the anterior roots. The reflexes of the legs are increased ; 
total compression of the cord may destroy the tendon reflexes; this 
is caused by secondary changes in the lumbar cord ; when the paralysis 
is flaccid, the urine is retained at first, and later there is incontinence. 
There is usually constipation. 

3. Disease of the First Two Cervical Vertebrae. — (Rust's Disease). — 
In disease of the atlanto-occipital articulation, nodding is impossible, 

08 



1074 DISEASES OF THE NERVOUS SYSTEM 

while the involvement of the odontoid-atlas articulation prevents turn 
ing of the head. In body-movements the patient supports the head 
with the hands (Rust). The head may be held as it is in torticollis, 
and induration under the occiput is common. Pains radiate to the 
eye, ear, and occiput. The typical paralysis in disease of the two 
upper cervical vertebrae is brachial paraplegia, which usually occurs 
without atrophy. Spasms in the face, anaesthesia in the neck and 
upper chest, aphonia and other symptoms indicating involvement of 
the medulla oblongata may be present. Charcot observed a slow pulse 
with attacks of syncope. The spinal accessory supply to the head and 
palate and the hypoglossus supply may be affected. The course is 
usually more rapid (one to two years) than in carcinoma; recovery is 
possible (v. Bergmann). It has long been held that degenerated axis 
cylinders do not regenerate, but Fickler made the interesting obser- 
vation that the fibers of the severed lateral pyramidal tract grew around 
the old scar to reach the anterior horns below it. Gravitation abscess 
may reach the neck or pharynx. Sudden death is not unusual, because 
dislocation readily occurs, since the disease is in the articulations rather 
than in the vertebral bodies. 

4. Lower Dorsal and Upper Lumbar Caries. — This type produces 
atrophic flaccid paraplegia, destruction of the lumbar reflexes, urinary 
incontinence, anaesthesia of the legs, pain in the abdomen or possibly 
in the groins or anterior thighs. When it occurs in the lower lumbar 
region there is flaccid atrophic paralysis, absence of the patellars, and 
spastic paralysis of the legs, with clonus of the Achilles tendon (see 
Conus and Cauda Localization). 

Diagnosis.— Cases may be classed under three groups (a) those with 
spine symptoms, (b) those with spine and spinal cord symptoms, and 
(c) those with cord symptoms only. Cases are almost unmistakable 
in which the paralysis follows signs of bone disease in early life. Re- 
peated examinations usually determine the nature of doubtful cases 
in which bone-symptoms develop after compression of the cord or 
nerve roots, and in which there are early increase of the skin or tendon 
reflexes, root-symptoms, which are usually bilateral, as cervical neural- 
gia, lumbago (Janeway), anaesthesia, and muscular atrophy or paral- 
ysis. The Roentgen rays may aid in diagnosis. Gravitation abscesses, 
fever, and tuberculosis elsewhere are significant. In persons of 
advanced years, cancer, tumor within the spinal canal and aneurysm 
must be considered (see Diagnosis of Cancer of the Spine). 

Prognosis. — The prognosis is unfavorable, since about 50 per cent, 
of cases die. Relative recovery with deformity is possible, especially 
in children, but even then the process may break out anew. A rapidly 
fatal course is rare. Absolute paralysis may disappear after months 
or even years. The prognosis is best in diseases of the lower dorsal 
region and is least favorable in disease of the atlas and axis. Gowers 
remarks that recovery or improvement is more frequent than in any 
other disease with symptoms of equal severity. There is hope of 
recovery in most cases, and yet there are few in which it is sure. Cystitis 



CARCINOMA OF THE SPIXE 1075 

is common, and leads to pyelonephritis; bed-sores are frequent, and 
death results from sepsis, mixed infection, amyloid disease or lung 
tuberculosis. 

Treatment. — (a) Medical treatment includes administration of iron, 
arsenic, and cod-liver oil; fresh air and a full diet are equally impor- 
tant. The skin and bladder should receive special attention. Elec- 
tricity is contra-indicated, (b) Orthopedic treatment produces the most 
successful results. Rest in bed on the back should be enforced for 
months. Extension, fixation by braces of the neck and back, suspen- 
sion, and for lighter cases or those involving the lower spine, the 
plaster cast, are described in works on orthopedic surgery, (c) Sur- 
gical intervention is indicated only when other treatment has been 
given thorough trial. The results are not encouraging and disease of 
the affected bodies is difficult of access. The dura should never be 
incised. According to Chipault, the indications are (i) disease restricted 
to the arches, (ii) cold abscess, (iii) flaccid paralysis, since Babinsky 
noted that this occurs in moderately severe dorsal disease, and (iv) 
healing of the bone focus and replacing of granulation tissue by con- 
nective tissue, as in the cases first operated on (Macewen, 1888). The 
contra-indications are (i) multiple vertebral disease, (ii) lung tubercu- 
losis, and (iii) disease of the cord itself. Victor Horsley advises ortho- 
pedic treatment for two months in children, and then, in case of 
failure, laminectomy. In adolescents and in those of advanced years, 
he considers that laminectomy is indicated practically at once. 



IV. Carcinoma of the Spine. 

Carcinoma is almost always secondary to carcinoma of the mamma 
and less often of the digestive tract, uterus, prostate or thyroid; it 
generally involves the bodies, usually of several vertebras. 

Symptoms. — Angular deformity is less common than in caries. A 
tumor may be felt. Bruns considers a sinking in of the vertebrae or 
softening of the spinal column as rather characteristic. Rigidity is 
common but is less conspicuous than in caries. Tenderness is common. 
The spinal symptoms closely resemble those of compression by caries, 
and are present in 60 per cent, of cases (Schlesinger). Compression 
of the posterior roots is most common and produces neuralgic 
pain, which is at first paroxysmal and later constant, lancinating, 
and incoercible; it is located along the spinal column, while in caries 
pain is felt over the spine or in the side of the chest (Gull). Closely 
associated are hyperalgesia and ansesthesia, tenderness on pressure, 
painful reflex muscular spasm and herpes zoster. Compression of the 
cord is less common and occurs late; if paralysis develops it is usually 
rapid and painful. The veins of the lower extremities thrombose 
frequently and fatal pulmonary embolism may result (Schlesinger ). 

Diagnosis. — Diagnosis depends upon (a) recognition of a primary 
cancer (which is sometimes latent or overshadowed bv the secondary 



1076 DISEASES OF THE NERVOUS SYSTEM 

deposit) ; (b) local signs (tumor, spinal irregularity, arcuate kyphosis) ; 
(c)f cachexia; id) advanced age, for caries commonly occurs in young 
individuals; (e) pain, which is usually bilateral and is increased by 
movement; paraplegia dolorosa (Cruveilheir) is much more common 
and incomparably more intense in cancer than in caries, from infil- 
tration of the sensory roots; anaesthesia with pain (anaesthesia dolorosa) 
is also common; and (/) rapid onset and course. Sarcoma may be 
primary or secondary. Cachexia is less common; it is more often 
seen in youth than in elderly persons, and is more frequently multiple. 
Vertebral syphilis is very uncommon, as gummata in the bone or 
periosteum, but responds to antisyphilitic treatment. Syphilis simulates 
caries rather than carcinoma. Actinomycosis rarely causes compres- 
sion of the cord; it is recognized by its presence in other organs 
and by the sulphur bodies in the sinuses and aspirated fluid. Arthritis 
deformans (q. v.) is recognized by exostoses, tenderness, ankylosis, 
in rare cases by crepitus, by alterations in other joints and by root- 
symptoms caused by narrowing of the foramina (radiating pains, 
vasomotor symptoms and atrophic paralysis). Aneurysmal erosion 
of the spine, cervical pachymeningitis, hydatids, exostoses, tumors 
within the spinal canal, glands compressing the intercostal nerves 
and tabetic pains in the trunk must be considered. The prognosis 
is absolutely unfavorable, and the treatment is directed chiefly against 
the pain. 

(C). DISEASES OF THE SPINAL MENINGES. 

Few diseases of the vertebrae and cord do not to some degree affect 
the meninges but, with few exceptions, the meningeal symptoms have 
little independent clinical interest. 



I. Hyperemia. 

At autopsy the blood gravitates to the dependent parts, and there- 
fore congests or discolors the meninges. At the present day but 
little importance is attached to the symptoms referred by Frank, 
Oliver and Brown-Sequard to meningeal congestion. Stasis, conges- 
tive diseases as tetanus, eclampsia, and chorea, or asphyxiating poisons, 
as carbon monoxide, or strychnine, doubtless congest the membranes. 



II. Hemorrhage. 

(a) Between the vertebrae and dura, hemorrhage is frequent from 
rupture of the subdural plexus of veins. It surrounds the nerve roots 
and is most severe over the posterior cord; it results mostly from 
trauma and to a lesser extent from convulsive affections, as tetanus, 
or strychnine poisoning, vertebral disease, stasis or aneurysmal rupture. 



PACHYMENINGITIS 1077 

(b) In the arachnoid sac hemorrhage (hsematorrh^chis) is equally fre- 
quent and results from the above named causes, and from asphyxia, 
extraction by the foot during labor, hemorrhagic diseases, or virulent 
leptomeningitis. Severe hemorrhage may follow brain hemorrhage, 
especially at the base (from rupture of aneurysm, or apoplexy) and the 
entire spinal canal may be filled with blood, (c) In the pia, hemor- 
rhage rarely attains either pathological or clinical interest. 

Symptoms. — Small hemorrhages cause no symptoms, and meningeal 
apoplexy may easily be overshadowed by brain or traumatic cord 
symptoms. Pain, localized in the small of the back or sometimes 
generalized, rigidity, radiating pains from compression of the posterior 
roots, hyperesthesia or hyperalgesia, painful reflex muscular spasms, 
motor weakness (and paraplegia), anaesthesia, sphincter disturbance, 
and abolition of the tendon reflexes are the common symptoms. 
They develop suddenly, affect the lower more than the upper cord, 
increase for a day or so, produce inflammatory reaction for two or 
three days and usually subside in from four to eight weeks. Physical 
signs vary with the location ; for instance, brachial paraplegia is present 
in cervical hemorrhage, and involvement of the legs in lumbar or 
dorsal hemorrhage. There are no cerebral symptoms, except those 
resulting from the initial shock in traumatic cases. 

In making a diagnosis the most important symptoms are those of 
irritation, which is sometimes followed by paralysis, while in hemor- 
rhage of the cord (hsematomyelia) paralysis prevails and pain is less 
frequent. In non-traumatic cases, exact diagnosis is impossible. The 
treatment is symptomatic. Absolute rest in the lateral decubitus or 
on the face should be enjoined. 



III. Pachymeningitis. 

(a) This may be external (peripachymeningitis), as described under 
caries. It may follow penetrating bed-sores, deep cellulitis, psoas or 
retropharyngeal abscess. Its symptoms are those of compression by 
vertebral caries (q.v.). Root symptoms and fever are frequent. The 
prognosis is unfavorable, and the treatment is that of the cause, or 
is expectant or surgical, (b) Internal pachymeningitis hemorrhagica 
is a second form. Its causes are those of the cerebral form, as paretic 
dementia, alcoholism, trauma and sometimes tuberculosis, (c) Char- 
cot (1871) and later Joffroy described a form involving chiefly the 
cervical region (pachymeningitis cervicalis hypertrophica) , in which 
the inner surface of the dura is thickened by annular concentric fibrous 
deposits. The dura adheres to the vertebrae and leptomeninges and 
compresses the nerve roots, which indurate. Several cervical segments 
are involved. The process is most marked on the dorsal aspect of 
the cord, which is flattened anteroposteriorly and shows peripheral 
induration by extension of the process to it through the pial vessels 
(meningomvelitis) ; this causes the frequent ascending and descending 



1078 DISEASES OF THE NERVOUS SYSTEM 

degeneration. Cold, syphilis, alcoholism and trauma are probable 
causes. 

Symptoms. — Charcot described three stages; (a) the neuralgic stage, 
which lasts two to three months, and corresponds to involvement of 
the posterior nerve roots, in which pains radiate from the nape of the 
neck or occiput into the ulnar and median nerve supply. They are 
continuous, with paroxysmal exacerbations, with localization at times 
in the arm joints, with rigidity as in caries, paresthesia in the arms, 
some motor weakness and sometimes vesicular eruptions. Hyperes- 
thesia is common, (b) The second stage is that of atrophic paralysis 
of the arms in which the process involves the anterior nerve roots. 
The pains are replaced by atrophy and paralysis in the ulnar and 
median nerve areas, while the radial area is usually unaffected; this 
produces flexor paralysis in the forearms and hands, and the claw 
hand (main en griff e) results from contracture; the wrist is over- 
extended, the first phalanges are extended, the second and third are 
flexed ; ulnar and median anesthesia and the reaction of degeneration 
are found. The shoulder and elbow muscles may be involved. Mus- 
cular atrophy is not constant and other deviations from Charcot's 
complex are at times noted, as absence of contracture or extension to 
the lower cord, (d) In the third stage, the legs show a spastic paralysis 
without atrophy, and the bladder and rectal functions and sometimes 
the sensory conduction are disturbed from secondary changes in the 
cord. 

Diagnosis. — The process is usually localized with ease as a disease 
in the cervical region. The marked pain is characteristic but may 
also occur in tumors, cervical spondylitis, syphilitic meningomyelitis 
and at times in syringomyelia. Some cases result from syphilis. Von 
Leyden and others maintain that diagnosis is usually impossible and 
that the process is not a unit but only a cervical localization of a men- 
ingomyelitis. Amyotrophic lateral sclerosis (q. v.) and progressive 
spinal muscular atrophy have no such severe pains, and syringomyelia 
(q. v.) is characterized by dissociated anesthesia as well as by muscular 
atrophy, painless felons and trophic changes in the joints. Tumors 
(q.v.) are difficult to differentiate. Neuritis causes symptoms which 
are usually limited entirely to the limbs, and over whose nerve trunks 
there is often tenderness. 

The prognosis is usually unfavorable, and chronic progression for 
two or more years, cystitis, etc., usually develop. Instances of recovery 
are recorded. 

Treatment. — Warm baths, cautery for counterirritation, sedatives, 
narcotics, mercury, iodides, and care of the skin and bladder are indi- 
cated. 

IV. Spinal Leptomeningitis. 

This closely corresponds to the description given under cerebral 
meningitis, as to the spinal, pathological and clinical findings. It 



TUMORS OF THE MEMBRANES 1079 

may occur (a) in the acute form, from trauma, regional extension from 
pleuritis, lung cavities, bed-sores or other adjacent infections, from 
general infections, and from epidemic, suppurative or tuberculous 
meningitis; or it may occur (b) in the chronic form, which has little 
independent clinical interest, which results from tabes, trauma, myelitis, 
syphilis (q. v.) or alcoholism. The symptoms are pain in the back, 
rigidity, hyperesthesia, and radiating pains; the course is afebrile. 



V. Syphilitic Affections. (See Syphilis.) 
(D). TUMORS OF THE SPINAL CORD AND ITS MEMBRANES. 

These are rare; about 200 cases are reported. Brain tumors are 
six times as frequent (Schlesinger). 

I. Tumors of the Membranes. 

These may arise from the dura or leptomeninges. In a collection of 
20 extradural tumors, Horsley found five sarcomata, four lipomata, 
four tubercles, three echinococcus cysts, and one each of myxoma, 
fibrochondroma, carcinoma, and fibrosarcoma. Cysticercus often 
causes no symptoms. These growths are more likely to cause erosion 
of the vertebra? than compression of the cord. Intradural tumors are 
nearly twice as frequent. Horsley collected 38, of which there were 
twelve myxomata, seven sarcomata (endotheliomata), seven fibromata, 
four psammomata, four tubercles, two parasitic, and two syphilitic 
tumors. Lipomata, echinococci, cysticerci, neuromata and angiomata 
are rarer. Though they are usually single, multiple occurrence may 
be noted in sarcomata, parasitic tumors and neuromata. This group 
compresses the cord or its nerve roots. The cord is altered as in caries ; 
there is oedema, flattening, discoloration, peripheral hardening and 
central softening, and secondary ascending and descending degenera- 
tions. The membranes thicken and the nerve roots flatten and atrophy. 

Symptoms. — Extradural growths produce more vertebral than cord 
symptoms. The first symptoms are usually those of compression of 
the nerve roots, e. g., rigidity; hyperesthesia ; radiating pains, first on 
one side, then on both, which run into the arms, trunk or legs, according 
to their localization, and advance from one root to another; pares- 
thesia; anesthesia which is less common since it implies involvement 
of at least three roots (Sherrington's law); atrophic paralysis with 
vasomotor symptoms; and spontaneous muscular contractions. Local 
tenderness is rare. Early symptoms sometimes date from trauma. 
The symptoms recall those of carcinoma of the spine aside from its 
vertebral signs. Later, evidences of compression of the cord appear, 
as paresis perhaps of one side first (Brown-Sequard's type, v. i.) or 
paraparesis with atrophy if the anterior horn is involved at that level, 



1080 DISEASES OF THE NERVOUS SYSTEM 

with increased reflexes (unless the arc is broken or total compression 
results), with spasticity and contractures; and with sensory changes. 
In this type, as in carcinoma of the vertebrae, the paraplegia dolorosa 
of Cruveilhier is common, as is anaesthesia dolorosa (the "eccentric 
projection" or reference of pain to the anaesthetic areas). Finally, 
there is total paraplegia, anaesthesia, bladder and rectal paralysis and 
decubitus. 

II. Tumors in the Cord Substance. 

These are six times less common than tumors in the membranes; 
they include glioma (which is most frequent in the cervical and upper 
dorsal regions), sometimes gumma, sarcoma (in thepia), tubercle (in 
the gray substance or posterior horn) and cysticercus. Most of them 
are circumscribed, though glioma tends to vertical diffusion. Unlike 
meningeal tumors, they are rarely metastatic. 

Symptoms. — In intramedullary growths, root symptoms are absent, 
especially in gliomata and, since there is gradual compression of the 
cord, the clinical picture may resemble chronic myelitis and syringo- 
myelia. The cord symptoms are disturbed conduction; spastic para- 
plegia; marked increase of reflexes (unless the arc is broken or absolute 
cord compression develops) ; bilateral symptoms, or if unilateral, they 
soon reach the other side; extensive muscular atrophy, if the cervical 
or lumbar enlargement is diseased, often then with the reaction of 
degeneration; and sensory changes involving all varieties of sensation 
or certain varieties only, as pain or temperature (dissociated or par- 
tial anaesthesia). Some writers, as Bruns, maintain that the lesion 
and symptoms are at first unilateral. Then the Brown-Sequard 
complex is found; on the side of the tumor there is paralysis with 
increase of the reflexes, loss of muscle sense, a zone of anaesthesia 
just below and one of hyperaesthesia just at the level of the lesion, 
and on the other side there is total anaesthesia save that the muscle 
sense is preserved. As the tumor grows, total paraplegia and anaes- 
thesia may, in rare cases, develop below the level of the lesion aided 
perhaps, by softening, oedema, or actual myelitis. 

Localization. — Accurate determination of the localization is most 
important but this can rarely be done until the cord itself is compressed. 
The most common error is in locating the tumor too low. Atrophic 
paralysis, in the cervical or lumbar regions, is the most certain aid, 
and sensory changes are less reliable. The actual lesion is one or 
two (three or four) segments higher than the anaesthesia (Sherrington's 
law) because anaesthesia results only from involvement of at least three 
roots. The hyperaesthesia usually represents the level of the lesion, 
and local spinal tenderness, though rare, is very important. Finally, 
the spinal segment involved must be considered in terms of the corre- 
sponding vertebrae (v.s., page 1061 Gower's cut), (a) When the tumor is 
in the upper cervical cord, there are pains in the cervical plexus and per- 
haps anaesthesia; at first after the Brown-Sequard syndrome, there 



TUMORS IN THE CORD SUBSTANCE 1081 

may be a spinal hemiplegia differing from cerebral hemiplegia in thai/ 
the face and hypoglossus escape and the anaesthesia is contralateral 
to the paralysis; then there is spastic paralysis of all four extremities, 
which rarely lasts long, since affection of the phrenic nerve causes 
early death, (b) In tumor of the cervical enlargement there is atrophy, 
flaccid paralysis and pain in one arm, spastic paresis in the leg of the 
same side, anaesthesia of the entire opposite half of the body and 
opposite limbs; and then paralysis of both arms and legs with anaes- 
thesia, (c) Localization in the dorsal cord often produces unilateral 
signs, as paresis of one limb with its half of the trunk, and anaesthesia 
of the corresponding parts of the other side; spastic paraplegia of 
legs and abdomen, retention of urine and later incontinence; and 
then girdle pains, (d) In tumors of the lumbar enlargement there are 
unilateral pains in the lumbar plexus and atrophic paralysis in the 
ileopsoas, quadriceps, and adductors; there is total anaesthesia when 
the cord is involved in the region of the lumbar plexus; later partial 
anaesthesia (affecting the sense of temperature and pain) develops in 
the region of the sacral plexus; still later there is complete paralysis 
and anaesthesia in the region of the lumbar plexus, with atrophy, 
absence of the patellar reflexes, with the reaction of degeneration, while 
the legs and feet are spastic, and with clonus of the Achilles tendon, (e) 
If the localization is in the sacral cord, there is atrophic paralysis of 
the leg and foot, of the posterior muscles of the thigh, of the gluteal 
and perineal muscles, anaesthesia, total paralysis of the bladder and 
rectum, impotence, loss of the Achilles tendon reflex (while the patellars 
may remain), early decubitus and cystitis. (/) If the tumor is in the 
cauda, the symptoms are usually bilateral from the beginning; the 
Brown-Sequard complex cannot occur; paraplegia is rarely as sym- 
metrical as it is in cord lesions; typical reaction of degeneration is 
indicative of caudal disease; pain is violent, since many sensory fibers 
are in close contact; Minor described bilateral and even unilateral 
sciatica as an early symptom. The sacral plexus is chiefly or first 
involved, while growths of the lumbar enlargement affect both the 
sacral and lumbar plexus. 

Diagnosis. — The diagnosis of meningeal tumor, which is always 
most difficult, is based on (a) local pain and rigidity, which is especially 
marked in the extradural type; (b) hyperalgesia; (c) radiating pains, 
i.e., root symptoms which later, by gradual transition, give way to 
(d) cord symptoms, which are usually or often unilateral at first and 
then bilateral, as interrupted sensory and motor conduction, and 
increase of the reflexes. Carcinoma of the vertebrae produces more 
pain on movement than other tumors. In caries there is less pain, 
local vertebral changes eventually appear, and the course is usually 
more rapid. In myelitis the focus is less commonly near the cervical 
enlargement, and therefore the arms are less often paralyzed. In 
myelitis, radiating pains may occur, but are much rarer than in tumor, 
and a girdle sensation is more common. The local pain sometimes 
suggests aneurysm, lung disease or peripheral neuralgias, the tender 



1082 DISEASES OF THE NERVOUS SYSTEM 

points of which are always absent. Other symptoms in the sequence 
above given must be present for diagnosis. A quiet course, root 
symptoms, early interruption of cordal conduction and absence of 
trophic disturbance in the bones and of dissociated anaesthesia argue 
for tumor and against syringomyelia. A diagnosis of tuberculosis or 
syphilis is fortified by their presence in other organs. Age is of diag- 
nostic importance: in youth, tubercle; at puberty, sarcoma and glioma; 
in the third and fourth decades, glioma, tubercle or sarcoma; and in 
advanced years gummata are most frequent. Diffuse sarcomatosis is 
usually cerebrospinal, rarely invades the cord substance as do gum- 
mata and tubercles, affects the posterior cordal surface most frequently 
(the lateral surface little, and the anterior very rarely) and generally 
in the lumbar and lower dorsal regions ; it occurs largely in the young 
and its course is rapid. Abscess of the cord is most rare. Tabes in 
one remarkable case was simulated by multiple tumors of the posterior 
roots. Tumors of the cord are more difficult of differentiation, for root 
symptoms are often lacking. 

Course and Prognosis. — Slow development, progression which is 
either steady or "by starts/' sometimes remissions, and eventual 
compression of the roots or cord are usual, with death from cystitis, 
or decubitus. Sudden paralysis is less common. The average dura- 
tion is one to three years, but a longer course is possible (even ten to 
fifteen years). 

Treatment. — 1. Therapeutics. — Narcotics must be employed to 
relieve pain, but should be used sparingly in the early stages, because 
if given freely, their effect may fail later if the course is protracted. 
Syphilis is always a possible factor; absence of evidence or history 
of the disease counts for little, and the patient should receive the 
benefit of antisyphilitic treatment. 

2. Surgical Treatment. — Gowers in 1887 localized a case of fibro- 
myxoma which Horsley removed successfully; this was the first case 
on record. Bruns collated twenty cases of operation; 33 per cent, 
of them recovered or improved. Putnam and Warren collected 33 
operated cases, with over 50 per cent, recovery. Tumors of the cord 
are less favorable than those of the meninges. Intramedullary tumors 
may only crowd the nerve paths, but their removal is often attended by 
danger of laceration or acute myelitis, which may possibly result in dam- 
age equal to that of the tumor. Accurate localization is most important, 
because, in one case, after removing parts of several vertebrae in 
vain, further search for the suspected growth had to be abandoned. 
Therefore, Urban's osteoplastic resection is valuable; it consists of 
folding back the cut muscles and bone that they may be replaced 
and the strength of the spinal column may not be impaired. Death 
may result from shock, escape of cerebrospinal fluid (Chipault) and 
less frequently, with modern methods, from infection. Starr records 
16 complete recoveries. Harte in 1905, collected 92 operations; the 
operative mortality was 47 per cent.; of the balance, 59 per cent, 
were cured, 34 per cent, improved and 7 per cent, not improved. 



HEMORRHAGE IN THE CORD 1083 

(E). CIRCULATORY DISTURBANCES; HEMORRHAGE; TRAUMA OF 

THE CORD. 

I. Hyperemia of the Spinal Cord. 

As in the spinal meninges, postmortem hypostatic congestion is com- 
mon, especially in the dorsal aspect of the cord. Sometimes the mem- 
branes are hyperaemic and the cord anaemic. The white matter is 
usually pale. The cord may be passively congested, as in cardiac 
insufficiency. Vascular variability was formerly considered causal of 
spinal irritation which, however, is functional (hysterical and neuras- 
thenic). No definite clinical picture can be constructed. 



II. Anemia of the Spinal Cord. 

Paralyses referred to anaemia of the cord are without doubt mostly 
due to neurosis, neuritis, hemorrhages in the cord or nerve sheaths, and, 
in pernicious anaemia, to degeneration of the dorsal columns. Paralysis 
following profuse hemorrhage from the stomach or uterus may be pro- 
perly referred to cord anaemia. Stenson (1667) demonstrated experi- 
mentally that compression of the aorta produced paraplegia due to 
anaemia of the cord, the motor cells of which appear to be especially 
susceptible to ischaemia. The symptoms are referred by others to 
anaemia of the peripheral nerves. Ligature or compression of the 
aorta after ligature of both subclavian arteries has identical effects 
(Kussmaul and Tenner). 

III. Embolism and Thrombosis (Myelomalacia) of the Spinal Cord. 

Embolism of the spinal arteries is extremely rare, but has been 
observed in endocarditis (v. Leyden, Weiss.) No separate clinical 
symptoms can be recognized, although experimentally Money observed 
choreiform movements. Thrombosis is very rare. Venous throm- 
bosis is rare, and is secondary to other lesions of the cord. Arterial 
thrombosis is rather more common. It has been found in syphilis, 
multiple sclerosis, senility and perhaps bears some relation to acute 
processes in the cord, as disseminated or focal myelitis. It is often 
impossible to decide whether an area of softening is ischaemic (myel- 
omalacia) or inflammatory (myelitis). 

IV. Hemorrhage in the Cord (Haematomyelia). 

Etiology and Pathology. — Most cases of this rare lesion occur in 
men between 20 and 40 years of age. (a) Capillary hemorrhages 
rarely cause symptoms; they occur about larger extravasations of blood 



1084 DISEASES OF THE XERYOUS SYSTEM 

in foci of softening, in inflammation, stasis, intoxications, infections or 
blood diseases, (b) Hemorrhagic infiltration occurs diffusely, and 
chiefly in areas of softening or near larger foci of hemorrhage, (c) 
The larger hemorrhagic focus may result from trauma, muscular 
effort, caisson-disease, etc; it compresses and destroys the cord sub- 
stance; it rarely exceeds the size of a hazelnut (round or oval form) 
but may extend through the entire length of the cord (tubal form of 
Levier), following exactly the less resistant gray matter, while the firmer 
white columns (pyramidal tracts) usually resist its lateral diffusion ; if it 
invades the white matter, hemorrhage usually occurs in the posterior 
columns; it occurs mostly in the cervical cord; all large non-traumatic 
hemorrhages occur in the gray matter. Effused blood undergoes the 
same fate as in other parts; it turns brown, then yellow-red, and ulti- 
mately deposits dark pigment and haematoidin crystals. The nervous 
tissue is disorganized by larger hemorrhages, which form in it a 
cavity. Eventually a pigmented apoplectic scar or cyst results. 

Symptoms. — The symptoms vary with the different forms, (a) In 
the accessory form there is bleeding into a tumor, cavity, softening 
or inflammation (Charcot, Hayem, Koster); punctate hemorrhage 
may accompany other affections, as hemorrhagic purpura, stasis or 
convulsive disorders, and few or no symptoms develop, (b) The trau- 
matic (see Trauma) form is less important in spinal fracture than 
concussion; it may develop during dystocia or foetal extraction. 
Trauma causes 90 per cent, of cases of haematomyelia (Oppenheim). 

3. The spontaneous form is rarer than it is in the brain, because 
the cord is firmer, subject to lower blood pressure, and most rarely 
the seat of miliary aneurysm ; it results from sudden exertion in man 
(and more often in the horse), from repeated coitus, suppressed men- 
struation or rarely from arteriosclerosis. 

The onset is sudden, without prodromes or loss of consciousness. 
Previous symptoms may suggest a hemorrhage into an inflammatory 
focus. Local symptoms must vary with the structures involved, and 
their level; they embrace paraplegia, monoplegia, often the Brown- 
Sequard syndrome, paralysis with or without atrophy or spasticity, 
anaesthesia either total or partial (i. e., dissociate, as in syringo- 
myelia, Minor), as might be anticipated from its location in the gray 
substance and posterior horns; pain at the level of the lesion, perhaps 
from involvement of the posterior horn; less often eccentric pain, 
girdle sensation and muscular rigidity. The reflexes and sphincters 
vary with the level. In general the reflexes are increased in small and 
abolished in large hemorrhages. The symptoms advance rapidly and 
may suffer an accession from secondary reaction or myelitis. Early 
death is rare. Late death from cystitis or decubitus is more common. 
Recovery is rare, compared with recovery in cerebral apoplexy; it occurs 
most often in the punctate type ; it is rarely absolute and some disturb- 
ance in motility or sensation usually remains. 

Diagnosis. — The diagnosis is usually only probable; it is based on 
the sudden onset of paresis and anaesthesia and their rapid advance. 



CAISSON OR DIVERS' PARALYSIS 1085 

For differentiation from meningeal hemorrhage (hosmatorrhachis) , see 
page 1077; in the latter, meningeal irritation is more common, as 
marked and radiating pains, rigid spine and muscles, hyperesthesia of 
the skin and muscles; paralysis is absent or incomplete; and recovery 
is more complete. From acute myelitis, differentiation is often uncer- 
tain and frequently of only academic interest, since each affection may 
complicate the other and the prognosis and treatment of each are 
similar. In myelitis and anterior poliomyelitis elevation of temperature 
is distinctive. 



V. Caisson or Divers' Paralysis. 

According to Pol and Watelle (1854), this occurs in workers who are 
subject to pressure of at least 2, and usually 3 or 4 atmospheres. 
Symptoms appear when the individual comes suddenly into the open 
air. They vary, and include transient pain in the ears, sometimes 
deafness and vertigo, headache and pains in the limbs, joints and epi- 
gastrium; in 15 to 50 per cent, there is paraparesis or paraplegia, 
sometimes with anaesthesia, and usually with urinary retention ; much 
less often there is hemiplegia or involvement of both arms; epistaxis, 
mental symptoms; loss of consciousness, and symptoms of brain- 
pressure, as vomiting or slowed pulse. Men of heavy build, alcoholics, 
and "new hands" seem to be predisposed; hard exercise after coming 
into the air produces unhappy symptoms, which are not severe or are 
absent if the interval of work does not exceed one hour. 

Pathology and Pathogenesis. — The pathology and pathogenesis 
are undetermined. Hoppe-Seyler (1885) and Bert found that lessened 
atmospheric pressure liberated oxygen, nitrogen or carbon dioxide in 
the blood and tissues, which ruptured the vessels and tissues and 
promoted punctate hemorrhage. In the first autopsy made, v. Leyden 
found clots in the cord substance, particularly in the posterior and 
lateral columns, surrounded by round cells (reactive disseminated 
myelitis); most changes were in the dorsal cord, the tissues of which 
are less compact; secondary degeneration is found (von Rensselaer) 
and changes in the gray substance (Schultze) which are thought to 
result from hemorrhage; Catsaris actually saw gas bubbles in the 
blood. Under moderate pressure the gas is given off to the lungs, 
while in extreme instances it is given off to the tissues. The symptoms 
apparently result less from the gas bubbles (air embolism) accumulat- 
ing in the blood under high pressure, than from its sudden reduction 
and the reactive apoplective myelitis. Andrew H. Smith holds that 
the lesion is cordal congestion and stasis. 

Prognosis. — A few subjects die at once; others die from cystitis, as 
in myelitis; about 50 per cent, recovers completely and 50 per cent, 
partially, with spastic paresis. The mortality ranges from 2.7 to 15.8 
per cent. 



1086 DISEASES OF THE NERVOUS SYSTEM 

Treatment. — The return to normal atmospheric pressure should be 
made gradually; recompression is successfully employed. Smith 
recommends ergot. 



VI. Trauma of the Cord. 

Compression by caries, tumor and carcinoma have been considered; 
other surgical lesions can only be touched on here. Crushing of the 
cord may be associated with hemorrhage, myelitis and secondary 
degenerations. Total division of the cord may result from fracture, 
gun shot or stab wounds; it is extremely rare; early death is usual; 
its symptoms are absolute paraplegia, anaesthesia, bladder paralysis, 
and abolition of the patellar reflexes. A recently reported case of 
total section with operation and recovery was received with some 
skepticism. Gun shot wounds usually result in fracture, crushing and 
sometimes actual division; as a rule the prognosis is unfavorable. 
Stab wounds may produce bilateral symptoms, or unilateral signs, as the 
Brown-Sequard paralysis; 20 per cent, recover; 60 per cent, improve 
and 20 per cent, of cases die (Wagner and Stolper). Restitution of 
function in lesser injuries results not from regeneration but from com- 
pensation by other paths of conduction. Laminectomy is indicated 
only in crushing injury of the lower half of the spine, because cervical 
cases almost never recover (Harm). 



VII. Brown- Sequard's Paralysis. 

This was described by Sequard and Ttirck simultaneously in 1850. 
According to Brown-Sequard's original proposition, on the side of 
section (cervical cord) there occurs (a) paralysis of voluntary motion, 
muscle sensibility and vasomotor tonus; (6) hyperesthesia of trunk 
and limbs, to touch, pain, heat and cold; (c) vasomotor paralysis of 
face and eyes (higher temperature, narrow pupils, and moderate 
contracture of certain facial muscles). On the contralateral side there 
is anaesthesia of all varieties of sensation, except muscle sensibility. 

Symptoms. — Exact hemisection of the cervical cord produces a 
spinal hemiplegia on the side of the section, but in clinical injuries and 
experimental section, the trauma is rarely wholly complete or strictly 
unilateral. (In some cases decussation of the uncrossed pyramidal 
tracts may occur in the cord lower down than the usual crossing point 
in the medulla [Flechsig] and spinal hemiplegia with contralateral 
monoplegia may result from unilateral lesion. Dejerine and Thomas 
speak of a third "homolateral pyramidal" tract, which may cause 
restitution of motor function. Edinger mentions a "reserve" inner- 
vation by which decussation of motor fibers occurs lower than the 
pyramidal decussation in the medulla). The most characteristic 
clinical type is the mid-dorsal lesion, but in cervical section or in 



BROWX-SEQUARD'S PARALYSIS 



1087 



pathological foci, paresis of the arm with paralysis of the leg is more 
usual, because the cervical motor tracts are less compact than they 
are in the lower cord; i.e., paralysis is more frequently limited to a 
group of muscles than to an entire upper extremity. "Conversely, 
paralysis of the leg may be incomplete, while that of the arm is com- 
plete, owing to the escape of fibers for the leg which cross lower down 
in the cord" (Gowers). The paralysis often decreases with surprising 
rapidity, and if the anterior cells are intact it gradually becomes simple 



Fig. 74. 




Brown-Sequard's paralysis from a left- 
sided focus A , vaso-motor and motor 
paralysis; B andD, cutaneous anaes- 
thesia; C , hyperaesthetic zone. (Erb.) 




V 



Fig. 75. 
S S' 



VVS.M 



i X X it 



ill 
i li 

ill! 




\:^ : - 



(Combined from Brown-Sequard.) — F, Focus in left 
side of cord. V, Pyramidal fibers having crossed 
in medulla. V , Vasomotor fibers, not crossing 
in cord. Sm, Fibers for muscle sense, not cross- 
ing in cord: SS S' S', other sensory fibers crossing 
in the cord. The focus explains the classical signs 
and also how few of the crossed sensory fibers to the 
left side are involved (merely a zone of anaesthesia), 
while all sensory fibers to the right side are severed 
(hemianaesthesia) . 



weakness. The motor are restored more readily than the sensory 
functions. There is an inactivity atrophy of the muscles without 
abolition of faradic irritability and without reaction of degeneration; 
the paralysis may be spastic or flaccid. Respiration is rarely affected, 
and imperfect movement of the chest has never occurred. Involvement 
of the thoracic and abdominal muscles usually indicates a bilateral 
lesion. Swelling and oedema in the paralyzed members have been 
observed, and also swelling with pain in all the joints on the paralyzed 



1088 DISEASES OF THE NERVOUS SYSTEM 

side. The deep reflexes are usually exaggerated on the side of the lesion ; 
they are abolished in a sudden total transverse lesion of the lower 
cervical or upper dorsal cord. The skin reflexes are abolished or 
decreased on the side of paralysis, and on the opposite anaesthetic side 
they may be normal, absent or increased. 

Hyperesthesia (Fodera, 1823) occurs on the paralyzed side and also 
as a zone above the anaesthetic area and near the level of the lesion. 
If the lesion be cervical or lumbar, the anaesthetic or hyperaesthetic 
areas above are not zonular but irregular. Hyperesthesia has been 
referred to the wound itself or to paralysis of inhibition. Hyperes- 
thesia or hyperalgesia concern tactile, pain, and heat and cold sensa- 
tions, and their absence infers incomplete section (Kocher). It usually 
disappears rapidly. The fibers, the section of which results in hemi- 
anaesthesia, lie in the lateral tract near the cerebellar and pyramidal 
tracts. 

The zonular anaesthesia on the side of the injury and of motor par- 
alysis is readily explained since the lesion involves not only the sensory 
fibers (which are ready to decussate to the other side and produce the 
crossed hemianaesthesia), but also implicates sensory fibers from the 
contralateral side, which have just decussated to the side of section. 
Abolition of muscle sensation on the side of the lesion is fully in accord 
with the uncrossed course of the muscle sense fibers in Burdach's col- 
umn, entering GolFs column higher up. Muscle sense is preserved on 
the side opposite to Jhe lesion. Vasomotor paralysis occurs on the 
side of section, as the vasomotor fibers course in the anterolateral col- 
umns. "Sensation is affected on the opposite side, but not quite up to 
the level of the lesion, because the decussation of the sensory tract is 
not immediate but occurs somewhat above the entrance of the nerve" 
(Gowers). Complete crossed hemianaesthesia occurs clinically in 
about 60 per cent., and partial anaesthesia (analgesia and thermo- 
anaesthesia) in about 40 per cent, of cases. 

Prognosis. — In clinical and experimental cases almost complete 
restitution to normal is possible; it is not due to reestablishment of 
conduction in the severed tracts, in which ascending and descending 
degeneration occurs, but rather to assumption of function by the unin- 
jured side of the cord (Kocher). The prognosis and treatment of Brown- 
Sequard's paralysis vary with the etiology of this symptomatic syn- 
drome, which may be syphilis, tumor, sclerosis, myelitis, tuberculosis, 
trauma, haematomyelia, fracture or luxation. 

VIII. Concussion of the Cord. 

Gussenbauer referred the severe symptoms, as paralysis, to hemor- 
rhage, which is produced in turn by movement of the cerebrospinal 
fluid. Long ago Ollivier explained the symptoms as being due to 
molecular alteration in the nervous tissue; this was confirmed by cases 
of experimental concussion (Schmaus and Bikeles) which resulted 



ACUTE MYELITIS 1089 

in degeneration of the cells and cylinders. Myelitis and chronic 
degeneration may follow concussion. The " railway spine " (Erichsen) 
is one of the traumatic neuroses. Obersteiner considers that long 
continued moderate jarring, as in the case of tramway drivers, may 
injure the cord. Symptoms develop at once or sometime later, as 
paraparesis, paraplegia, retention of urine and anaesthesia, less often 
than paresthesia. Some cases recover after months to a year or two. 
In others the symptoms are permanent; in still others death, usually 
early, occurs. In diagnosis, fracture, hsematorrhachis, hsematomyelia 
and traumatic neurosis should be considered. Simulation, in order to 
obtain damages for accidents, may be difficult to exclude, but some 
railway surgeons and medical experts in corporation employ, err in 
discounting the importance of concussion and traumatic neurosis 
(q. v.). Paraplegia and retention of urine are indicative of structural 
alteration of the cord. Treatment consists of rest, local application of 
cold and avoidance of neurotic tendencies. 



(F). INFLAMMATION OF THE CORD. 

Myelitis is inflammation of the cord. It was described by Oliver 
and Abercrombie a century ago; the term has long been made to 
cover many affections which are not properly inflammatory, as com- 
pression paralysis. Oppenheim and Marie have vigorously disputed 
the opinion of Gowers, v. Leyden, and Erb, that myelitis is a frequent 
affection. 



I. Acute Myelitis. 

Etiology. — There are two prominent causes, infections and intoxi- 
cations. The affection occurs largely in males between ten and forty 
years of age. 

1. Acute Infections. — Experimental myelitis has been produced by 
the B. pyocyaneus, B. diphtherias, B. coli, B. typhosus, strepto- and 
staphylococci, avian and human tuberculosis. French writers have 
contributed most to this subject. It has followed epidemic menin- 
gitis, variola, typhus, measles, rheumatism, and other infections, caused 
(a) by the germs themselves or secondary infection (focal myelitis re- 
sulting) or (6) by their toxins (disseminated myelitis resulting). 

2. Intoxications. — These include poisoning by alcohol, ergot, and 
lead, and perhaps auto-intoxications, as in cancer, or severe anaemia. 

All other causes are doubtful; trauma (fracture, concussion, com- 
pression by caries or cancer) is often considered of etiological impor- 
tance but probably causes softening or hemorrhage, to which infection 
may of course be added; exposure to cold and dampness most likely 
reduce the physiological resistance, thus indirectly favoring localization 
of bacteria; syphilis (q. v.) may affect the meninges and cord (meningo- 

69 



1090 DISEASES OF THE XERVOUS SYSTEM 

myelitis), but the so-called syphilitic myelitis is usually ischsemic 
softening from vessel changes. The etiological importance of sexual 
excesses and emotional shocks is at present sharply questioned, as is 
von Leyden's theory that infection from the bladder may reach the cord 
by ascending neuritis. 

Pathology. — On macroscopic examination we find redness and 
swelling; on cross section, blurring of the cord tissues, and decreased 
consistency, even to fluidity; as in the brain, "red softening" (hemor- 
rhagic myelitis), and in older cases "yellow softening" from fatty 
change, or "white softening" and cavity formation occur. Myelitis 
can usually be seen to best advantage after hardening in Miiller's 
solution, the normal tissue then appears green and the diseased, yellow. 
In the ultimate stages, atrophy, cyst formation, induration and very 
rarely abscesses are found. Microscopically there are, in fresh cases, 
degenerated swollen axis cylinders, the disintegrating medullary 
sheaths of which may form myelin drops; granules and granule cor- 
puscles (leukocytes or vessel endothelial cells); extra vasated red and 
white cells; turgid vessels the nuclei of which proliferate; choking of 
the perivascular lymph spaces with cells; degeneration, blurring and 
vacuole formation of the nerve cells the processes of which shrink and 
the nuclei vanish; granular amorphous deposits of coagulated albumin 
in and about the cells; in some cases the parenchymatous far exceeds 
the interstitial alteration, and often parenchymatous myelitis were 
better called parenchymatous degeneration. The gray matter (polio- 
myelitis) is involved much more often than the white (leukomyelitis). 
In older cases, there are corpora amylacea, empty spaces corresponding 
to destroyed nerve fibers; large "spider" cells with many processes 
(Deiter's cells); and there is disappearance of the vascular changes 
and substitution of destroyed tissue by focal interstitial proliferation. 
In rare instances bacteria are found, as streptococci, or the colon or 
typhoid bacilli, but probably the toxins are more important than the 
organisms. The microscope differentiates between the ischsemic 
inflammation and postmortem softening. The degree and the extent 
of inflammation vary greatly; transverse myelitis may destroy an 
entire cross section; or disseminated foci may involve at random 
various structures at different levels. Meningomyelitis (perimyelitis, 
annular or cortical myelitis) chiefly affects the periphery of the cord, 
whence concentric invasion along the septa may split the cord struct- 
ures; this is frequent in the syphilitic form. Poliomyelitis (inflam- 
mation of the gray substance) is really a type of myelitis, but involving 
as it does only the anterior horns, is usually classified by itself. De- 
generation and inflammation of the motor and sensory roots may follow 
myelitis in the cervical or lumbar enlargement; secondary degenera- 
tions are common; the inflammation may ascend or descend the cord, 
but usually affects only one or two segments. 

Symptoms. — The symptoms vary with the extent, form and locali- 
zation. The localized form, limited to a small segment, is called 
transverse, while the diffused form is known as disseminated myelitis. 



ACUTE MYELITIS 1091 

Acute transverse myelitis is the prototype. The cord symptoms 
are usually first in time and always first in importance, and consti- 
tutional symptoms as fever, chills, malaise, and in children convulsions, 
sometimes may precede but usually attend the cord symptoms. The 
symptoms resulting from involvement of the cord are (a) paralysis, 
which is usually early, rapid but not apoplectic in onset, and is prom- 
inent, paraplegic, progressive, flaccid and rather complete. In 
complete paralysis, the flexors are usually weaker than the extensors. 
The toes alone may be moved; twitching of the paretic muscles is 
usually associated with pain. Clonic muscular spasms are sometimes 
present, inappropriately designated by Brown-Sequard as spinal 
epilepsy. The paralysis is often preceded for a short time by sensory 
phenomena, as numbness, or by darting pains in the limbs, joints or 
back, which are usually neither conspicuous nor severe ; it is less often 
preceded by hyperesthesia, local muscular contractions, or general 
convulsions, especially in children. The paralyzed limbs show a 
transient rise of temperature, followed by somewhat subnormal 
temperature. The limbs are often dry and may not sweat even after 
injection of pilocarpin (Brieger). (b) Sensation is frequently involved. 
The initial tingling pain has been considered. Anaesthesia may be 
complete to the level of the lesion, but more often incomplete (hypsesthe- 
sia), and rarely partial, according to the cordal tissues involved. It 
is higher anteriorly than posteriorly; a zone of hyperesthesia or " girdle 
pain" marks the upper level; it is caused by early irritation or late 
cicatrization. Severe pain suggests vertebral or root disease rather 
than myelitis; gastric crises like those of tabes, dysesthesia (Charcot), 
i. e., diffuse vibrating sensations over the entire limb from local 
stimulation, as by a needle, and ataxia (which is usually obscured 
by the paraplegia) are much less common, (c) At the onset all reflexes 
may be lost, but they are usually increased below the focus, because 
of lessening of the cerebral inhibition traveling in the lateral 
pyramidal tracts, the skin reflexes being increased early and the 
muscle reflexes later; involvement of their centres causes permanent 
loss of the reflexes; for instance, they are lost in the arms and increased 
in the legs in cervical myelitis; lost in the trunk and increased in the 
legs in dorsal myelitis; lost in the legs in lumbar myelitis, (d) The 
sphincters are affected almost constantly and early, perhaps even before 
the onset of paraplegia; initial difficult urination (ischuria) or urinary 
retention, possibly with sphincter spasm and later with incontinence, 
is usual; when the bladder is full it may dribble from relaxation of 
the sphincter: this is known as ischuria paradoxa or retention with 
incontinence; the patient may or may not be conscious of the retention, 
depending on whether the afferent sensory fibers are involved or not ; 
in lumbar myelitis incontinence prevails from the beginning. The 
urine is at first alkaline and later ammoniacal on the advent of cystitis. 
The sphincter am" acts involuntarily, i. e., is spasmodically contracted; 
the paresis of the bowel and abdomen are factors in constipation ; in 
lumbar myelitis the sphincter is paralyzed, (e) Trophic changes may 



1092 



DISEASES OF THE NERVOUS SYSTEM 



occur. 



Muscular atrophy and the reaction of degeneration are caused 
by disease in the anterior horns and the muscles also waste from in- 
activity. The skin is usually dry, sometimes glossy or the seat of 
papular or vesicular eruptions, shedding or over-growth of the hair. 



Cord Symptoms Grouped According to Localization. 

(Amplified from Morton Prince.) 



In order of fre- 
quency. 


Dorsal myelitis most fre- 
quent. 


Then Lumbar myelitis. 


Lastly, Cervical myelitis. 


Paralysis. 


Trunk, back, intercostal 


Trunk and arms normal. 


Neck muscles, diaphragm, 
arms, trunk and legs par- 




and abdominal muscles 


Paraplegia flaccid 




(favoring mucus stag- 


throughout (ant. horns 


alyzed. Typically, atro- 




nation in lungs). Arms 


involved). 


phic flaccid paralysis of 




normal. Paraplegia, 




arms (ant. horns invol- 




first flaccid then spastic 




ved), with flaccid, later 




(lateral columns in- 




spastic paralysis of legs 




volved). 




(lat. columns involved) : 
however, paraplegia 
brachialis with paralysis 
of legs is very rare. In 
rare lesions high in the 














cervical cord, the neck 








muscles atrophy and 








both arms and legs show 








simple, then spastic 








paralysis, without 








wasting. 


Atrophy. 


In trunk; difficult to elicit. 


None in arms or trunk. 


Atrophy of neck muscles 




In legs; only from in- 


Atrophy in legs: (ant. 


if high lesion (rare). 
Usually of arms only 




action. 


horn involved). 








(ant. horns involved at 








level of lesion). In legs 








only from inaction. 


Reaction of de- 


Present in trunk muscles; 


Present in legs or in mild 


Present in arms; (rarely 


generation. 


absent in legs (or only 


cases quantitative re- 


in neck). 




quantitative reduction). 


duction. 




Sensation. 


Girdle pain and hyper- 


Pain in loins or legs; hy- 


Pain and hyperesthesia in 




aesthesia, between ensi- 


peresthesia in loins. 


arm nerves (with highest 




form and navel. Anaes- 


Anaesthesia of legs. 


localization) ; anaesthe- 




thesia corresponding 




sia in arms (lower 




with motor paralysis. 




localization); and the 
trunk and legs. 


Reflexes. 


Superficial reflexes, initial 
loss, rapid return and 


Lost 


Superficial reflexes; initial 






loss, rapid return and 




increase. 




increase. 




Deep reflexes, initial loss, 


Lost. 


Deep reflexes; initial loss, 




slow return and increase. 




slow return and increase. 


Sphincters. 


Bladder, initial retention, 


Incontinence from begin- 


Same as in dorsal myelitis. 




later intermittent over- 


ning (sphincter paraly- 






flow or incontinence. 


sis). 






Cystitis common. 








Bowels, usually spasm of 


Incontinence (sphincter 


Same as in dorsal myelitis. 




sphincter ani; consti- 


paralysis) disguised, per- 
haps, by constipation. 






pation. 




Trophic changes, 


Decubitus from neglect, 


Decubitus, cystitis, etc., 


As in dorsal lesions. (Oc- 


etc. 


etc. 


from neglect and trophic 


casionally very high 






alteration. 


temperature.) 


Pupils. 


Klumpke's paralysis of 


Absent. 


Paralysis of pupil (lowest 




pupil (if in upper dorsal). 




cervical region). Optic 
neuritis in isolated cases. 


Priapism. 


Oftenpresent and painful; 
sometimes ejaculation 
at onset. 


None. Impotence. 


Priapism often present. 


Mode of death. 


Cystitis, decubitus. 


Decubitus, cystitis. 


Medulla symptom, vomit- 
ing, slow pulse; usually 
by involvement of 
phrenic nerve with early 
death. 



ACUTE MYELITIS 1093 

The joints are sometimes swollen and the limbs ©edematous. Bed- 
sores are frequent over the sacrum, trochanters, heels, between or even 
over the knees, from the bed covers; they result from neglect or in 
lumbar myelitis from trophic disturbance (disease in the gray matter 
or posterior horns). The same factors are said by some writers to 
cause cystitis, ulcerations in the bladder or urethra, and the tendency 
to cellulitis or phlegmon. 

Course and Prognosis. — The onset may take place in a few hours 
(the apoplectic form), or in several days to a week (the subacute form). 
Four stages are described, which however, blend : (a) the more or less 
acute initial stage; {b) the advancing degeneration; (c) the restitution; 
and (d) the stationary (residual or chronic) stage. Complete para- 
plegia and anaesthesia may persist, but more often sensation returns 
after some weeks, while movement returns far more slowly and incom- 
pletely, usually with some residual spastic paraplegia. Contractures 
may develop, especially in the adductors and the knee flexors, in which 
case the prognosis is particularly unfavorable, for profound disease is 
indicated. Contractures, muscular contractions, and increased re- 
flexes are caused by secondary degeneration. The immediate outlook 
in myelitis is always uncertain, and ultimate recovery is usually incom- 
plete ; it depends (a) on the etiology, the prognosis being best (Oppen- 
heim) in acute infections; (b) on the intensity of inflammation; (c) on its 
transverse or vertical dimensions, and (d) on the rapidity or tardiness 
of signs of improvement. Complete recovery in mild circumscribed 
forms is barely possible, since indirect symptoms, due to collateral 
oedema may disappear. Death results from extension to the medulla 
(causing slow pulse, and vomiting), phrenic nerve phenomena, and 
sepsis following cystitis, pyelitis, or pyelonephritis. A form of recur- 
rent myelitis is said to exist (my elite d rechutes). 

Diagnosis. — The early onset of structural cord symptoms, as reten- 
tion of urine, followed by paraplegia and by anaesthesia, is especially 
significant after acute infections. Very rarely is there local tenderness. 
The upper level of the myelitis corresponds to that of the paralysis or 
anaesthesia. The lower level may be determined by the condition of 
the reflex centres. Application of a weak faradic current shows to 
what extent the gray matter is involved. Anterior poliomyelitis (q.v.) 
does not involve sensation, and but rarely extends back of the anterior 
horns. Compression by caries, or cancer usually causes local vertebral 
changes and root symptoms precede cord symptoms. The so-called 
syphilitic myelitis is usually ischaemic myelomalacia; it begins acutely 
or subacutely without pain, and is rarely relieved by antisyphilitic 
remedies. Hemorrhage in the cord produces most sudden symptoms, 
and acute spinal pain without prodromes; a precipitate onset may 
cause confusion instead of being of diagnostic value, in case of apoplec- 
tic myelitis. For differentiation from Landry's paralysis, see page 
1102, and from multiple neuritis, see page 1145. Meningeal hemorrhage 
and meningitis produce unmistakable root symptoms. Abscess of the 
cord is rare, for few more than a dozen cases are reported; its symp- 



1094 DISEASES OF THE NERVOUS SYSTEM 

toms are essentially those of myelitis, plus meningeal symptoms. 
Hysterical paraplegia has a psychical etiology; it is characterized by 
other stigmata of hysteria, motiveless variability of the symptoms, 
little myotatic irritability, little extensor spasm (and then both legs 
move together when one spasmodically extended leg is lifted); rarely 
by incontinence of urine or faeces, no trophic changes, no cystitis, no 
reaction of degeneration, and no decubitus. 

Gower's scheme for diagnosis from the method of onset is here given: 

Disease. Onset. Disease. 

Sudden (few minutes). \ VascM1 , ar T • 

Acute (few hours or days), J ] V ascmar lesions. 
Pressure ] Subacute (1 to 6 weeks). \ Inflammation. 

and }■ Subchronic (6 weeks to 6 months). *' j t\ *.- 

r* . , v-n • f ii f 4.1 \ ) Degeneration. 

Growths. J Chronic (more than o months). 

In the chronic stage the diagnosis of what has gone before must be 
uncertain, unless the history is most definite; the diagnosis is usually 
provisional, and atypical cervical pachymeningitis, tumors, and most 
often multiple sclerosis of the spinal type, should be considered. 

Treatment. — This is symptomatic. In the acute stage, the indica- 
tions are (a) absolute rest in bed for at least two weeks, keeping the 
patient on one side or on the face, with possibly local abstraction of 
blood and local warmth. Blisters should be avoided lest they develop 
into decubitus, (b) Gowers recommends spt. etheris nitrosi with digitalis 
to equalize the circulation and promote diuresis, (c) When hemor- 
rhagic myelitis is suspected ergotin (grs. iij to v) may be given three 
times daily, (d) Mercury and iodides are usually without effect in 
syphilitic myelitis (softening) or are possibly directly injurious, 
although some rationally recommend their u.se unless unfavorable 
effects appear, (e) Care of the skin is necessary. Though bed-sores 
may be trophic, practical experience shows that care greatly reduces 
their frequency and extension. Pressure and heat should be avoided 
by change of posture, by use of rubber cushions, soft thick pads of 
cotton or the water bed. As in typhoid, the use of two beds is very 
beneficial, and the sheets should be stretched smooth. Alcohol rubs 
are antiseptic and harden the skin. Moisture and filth are most dan- 
gerous; the bowels should be irrigated if they move involuntarily; 
incontinence of urine is more dangerous, especially in women; hard 
urinals, if left between the legs, may cause equal damage; the urine 
should be gathered in bags of oiled silk filled with cotton; in women 
mild antiseptic gauze should be disposed about the genitalia. The 
author has used successfully the rubber dam used by Dr. Murphy in 
laparotomies, by spreading it over the sacrum and buttocks after care- 
fully cleansing and drying the skin and washing it with ether, before 
applying the dam. (/) Care of bladder is imperative. Cystitis develops 
in most cases in which the catheter is used, or in which there is incon- 
tinence with retention; residual urine is easily infected, probably by 
infection ascending the dribbling, patent urethra; the urethra should 



ACUTE POLIOMYELITIS OF CHILDREN 1095 

be irrigated before the absolutely clean catheter is introduced; lavage 
with Thiersch's solution in cystitis with retention or incontinence, 
and grs. v to x, each of urotropin and salol t.i.d. are indicated, (g) 
The paralyzed muscles should be gently massaged from the very onset. 
In the subacute or chronic stage, tonics, massage after four weeks, 
mild faradism of the muscles of the bladder and rectum (not those of 
the cord, and only when there is muscular wasting or incontinence) 
are indicated. Brans considers spinal galvanization most efficacious. 
Contractures are modified or prevented by warm baths and massage. 
Hot baths are directly dangerous. 



II. Acute Multiple Disseminated Myelitis. 

This affection is relatively infrequent, although of late more cases 
are reported. It is usually subacute in onset; foci develop irregularly, 
together or successively in different parts of the cord or perhaps of the 
brain (disseminated encephalomyelitis), with acute ataxia, scanning 
speech, dysarthria, tremor, nystagmus, optic neuritis, spasticity, or 
weakness of the limbs. Sensation and the sphincters are usually not 
affected. The clinical picture is necessarily irregular, because the inflam- 
mation may occur anywhere; von Leyden distinguishes (a) the atactic, 
and (b) the paraplegic form. A myelitis which spreads after the first 
two or three days is of the disseminated type, and may be fatal in a 
few days to a few weeks; though it was once thought very fatal, num- 
bers of recoveries have been reported lately. Treatment is as in the 
acute transverse varietv. 



III. Chronic Myelitis. 

This may be the stationary stage of a passed acute myelitis, or in 
very rare cases, myelitis may be chronic from the beginning, i.e., it 
may have a gradual onset and slow progression. Many deny the 
existence of this form and classify it under the paraplegic state, mul- 
tiple sclerosis, or chronic system-disease. If myelitis, chronic from the 
onset, is to be recognized, its symptoms differ from the acute form only 
or chieflv in the mode of onset. 



IV. Acute Poliomyelitis of Children. 

Acute poliomyelitis, also known as atrophic paralysis, was first 
described clinically by v. Heine (1840), and pathologically by Cornil 
(1863), although Prevost and Vulpian (1865) first accurately defined 
the changes in the ganglionic cells of the anterior horn. The famous 
contribution of Charcot and Joffroy (1870) fixed the trophic relation 
of the special cells involved to the atrophy of the nerves and muscles 



1096 DISEASES OF THE NERVOUS SYSTEM 

supplied, and stated that the disease was due to primary inflammation 
of the cells themselves. Archambault and Damaschino found the pri- 
mary inflammation in the vessels (interstitial myelitis). 

Definition. — An acute, probably independent, infection, character- 
ized pathologically by acute myelitis of the anterior horns, and clinically 
by the incidence in children of an acute flaccid paralysis with wasting 
in the muscles, loss of reflexes, the reaction of degeneration and later, 
contractures. 

Etiology. — In some statistics it constitutes as high as 8 per cent, of 
the diseases of childhood. 

1. Age. — The disease largely occurs between the first and fourth 
years of life (mostly in the second and third); 60 per cent, of cases 
occur in the first three years, and it is ten times as frequent in the first 
decade as in all the others. Its occurrence in youth is difficult to explain 
although Lange refers it to functional activity of the cord, as learning 
to walk, etc. It has no causal connection with dentition, as Under- 
wood thought, although often synchronous with it. 

2. It may follow such infections as measles or scarlatina, and Marie 
thinks that it may result from many others, (infectiones innomminees). 
In some localities it has occurred as an independent epidemic, as 
Caverly's series of 140 in Vermont, or Medin's series of 44 in Sweden. 
Alice Woods describes an epidemic of 60 to 70 cases in San Francisco, 
in May and June, 1901. 

3. Eighty per cent, of cases occurs in the summer months (Sinkler). 
Cold and trauma are improbable factors. Sex is of no importance, 
save after the tenth year, when the disease is almost entirely confined 
to males (Gowers). 

Pathology. — The affection is called poliomyelitis (Kussmaul), because 
it is an inflammation of the anterior gray matter, which is supplied by 
the central arteries of the anterior median artery of the anterior longi- 
tudinal fissure. A single vessel does not supply all the anterior gray 
matter, but branches up and down, supplying a cylindrical vertical 
area which measures two inches or more; this is the usual dimension 
of a poliomyelitic focus. The inflammation may extend somewhat 
back of the anterior horns into the white matter of the antero-lateral 
columns. Fresh cases are rarely seen, since death is unusual; to the 
naked eye, the focus is red, soft, juts above the cut section and is mostly 
confined to the anterior horn, i.e., it involves the beginning of the 
second (or lower) motor neurone. Microscopically, the lesion is inflam- 
mation in and about the vessels above named, in the anterior roots, 
and in the vessels even before they enter the cord. The vessels are 
engorged; their perivascular spaces are full of cells and granule-cells; 
there is exudation of red and white cells with actual hemorrhage in the 
severe cases, as shown by blood pigment; the ganglion cells in the 
anterior horn are swollen, glistening, granular, pale, distended, 
decreased in number, and surrounded by leukocytes; their dendrites 
may shrink, their nuclei disappear, or the whole cell may disintegrate, 
while here and there some cells escape; no definite cells are involved, 



ACUTE POLIOMYELITIS OF CHILDREX 1097 

since the process depends solely on the vessel affected. The involve- 
ment is sometimes bilateral, and in severe cases is distributed through 
several segments, especially in the lumbar cord. As may easily be 
anticipated, disease in the trophic cells of the lower motor neurone must 
be followed by degeneration of their axis cylinders, nerve roots, peri- 
pheral nerves and muscles (which become granular, fatty, and later 
indurated). In old cases, macroscopic inspection shows shrinking of 
the anterior horns, perhaps also of the contiguous white matter, with 
lack of differentiation between the gray and white matter. Micro- 
scopically, the (formerly inflamed) vessels are thickened and pig- 
mented ; groups of ganglion cells have disappeared, and their nerve fibers 
are degenerated or wholly wasted, which led Charcot to hold that the 
process was essentially in the ganglionic cells, but the connective 
tissue also is rich in cells and stains deeply with carmine, because it is 
thicker than normal; in other words, a cicatrix remains from the pri- 
mary inflammation. In severe cases, identical changes have been 
found in the medulla, pons, and centrum ovale. Acute poliomyelitis 
differs from acute myelitis and disseminated myelitis only in its locali- 
zation, for which there is no universally accepted reason; the gray 
substance is more vascular, and Lamy's experiments, in which he 
injected powder into the abdominal aorta, always showed embolic 
softening of the gray matter first. 

Symptoms. — There" are three clinical periods: 1. The acute stage 
(including prodromes) : 2. The stage of diffuse paralysis, when degen- 
eration appears and regeneration occurs: 3. The stationary stage, 
with some improvement and determination of the paralysis to given 
groups of muscles. 

1. The Acute Stage. — The typical onset is acute, appearing in a 
child previously well, with fever (75 per cent.), often with vomiting, 
headache, somnolence, and sometimes with convulsions or coma, 
which are followed by a sudden complete and flaccid paralysis in one 
limb or more than one limb; it corresponds to the acute inflammation 
in the anterior horn. The fever averages 101°, may reach 105° or more, 
and lasts about 24 hours. Convulsions are not as common as in the 
cerebral type; they occur mostly in younger subjects and are attributed 
perhaps to teething, which was once thought the cause of the paralysis. 
The simple motor paralysis usually reaches its maximum in twenty- 
four to forty-eight hours; it is not progressive; its distribution will be 
considered under the next stage. In some cases prodromata exist, 
which are not characteristic; they are malaise, anorexia, pain in the 
back and limbs or diarrhoea; their average duration is one to two days. 
Unusual variations in the onset are possible; the fever may last one 
or two weeks before the paralysis develops, it may be short, lasting 
for a few hours only, or may be absent throughout the entire course. 
The paralysis may develop during the night. Abortive cases are most 
exceptional and are probably often due to neuritis; the paralysis may 
follow some acute infection, as measles or scarlatina. Sometimes par- 
alysis is not noticed for a longtime, until, for example, the child fails 



1098 DISEASES OF THE XERVOUS SYSTEM 

to walk. In some cases pain is the first symptom in older children, 
and is referred to the back or extremities. Convulsions involve princi- 
pally the extremities, and sometimes occur in the form of clonic muscu- 
lar contractions; Strumpell observed them for more than a month 
before the paralysis developed. The onset may simulate acute 
rheumatism. 

2. The Stage of Degeneration. — This results from localization in the 
anterior horn, which produces (a) paralysis, (b) disturbed nutrition, (c) 
vasomotor changes and (d) loss of reflexes, (a) The paralysis is motor 
only; it is sudden, complete, flaccid and nonprogressive; though at 
first diffuse, it usually regresses, although incompletely, leaving some 
permanent paralysis. General localization, according to Starr's com- 
bined statistics of about 600 cases gives : (i) Paralysis, most frequently 
of one leg, then (ii) of both legs, and (hi) and (iv) of all four limbs or of 
one arm (with equal frequency), (v) of arm and leg of same side (spinal 
hemiplegia), (vi) of arm with opposite leg (crossed or alternating 
paralysis), (vii) of three limbs, and least often, (viii) of both arms. 
The trunk muscles may be involved, but the cranial nerves are almost 
always exempt, save in severe and diffuse foci. The bladder is usually 
unaffected, except in the early stage, from general toxaemia, or in severe 
cases. As to its special localization, the leg is paralyzed in 75 per cent, 
of cases (E. Remak); in one form, the lasting paralysis affects the 
quadriceps femoris with the adductors (upper lumbar lesion), but 
the sartorius is not involved ; in another form, the muscles below the 
knee supplied by the peroneal nerve, are involved, as the tibialis 
anticus, extensor digitorum communis, ext. longus or brevis, ext. hallucis 
longus, peronei (lower lumbar and upper sacral lesion) of which some 
muscles may escape as the tibialis ant., since total paralysis is rare. 
If both legs are involved, the paralysis is rarely symmetrical. Polio- 
myelitis usually involves several segments, because of the arterial dis- 
tribution. The arm is paralyzed in 25 per cent., chiefly in the form of 
the combined shoulder paralysis of Remak, involving the deltoid 
(sometimes alone), biceps, brachialis, supinator longus with the supra - 
and infra-spinatus and teretes (lesion in upper cervical enlargement, 
fifth to sixth segments) ; in some cases the forearm type may be seen, 
with involvement of the flexors or possibly of the extensors, while the 
supinator longus often escapes (lower cervical lesion, seventh and 
eighth segments). The trunk or neck muscles usually show improve- 
ment in this stage, (b) As to disturbed nutrition, the muscles and 
nerves corresponding to the level of the poliomyelitis rapidly degenerate 
as shown by early reaction of degeneration and muscular atrophy 
The reaction of degeneration consists of failure of the nerve and muscles 
to respond to the faradic current and usually appears in one or two 
weeks (Duchenne) or rarely earlier; it also includes a lack of response 
of the nerve to the galvanic current, and finally too prompt a response 
of the muscles to the galvanic current and more quickly to the positive 
than to the negative pole; this latter reaction lasts for two, three or six 
months and then gradually disappears in a year or two. Muscular 



ACUTE POLIOMYELITIS OF CHILDREN 1099 

atrophy may be apparent in two weeks and is more clearly seen in the 
arm than in the leg or trunk, whose adipose deposit may obscure it. 
Fibrillary contractions are rather frequent. The wasted flaccid mem- 
ber hangs and swings in a lifeless fashion, (c) Vasomotor paralysis 
causes the low temperature (1 to even 10° below normal) and the livid 
cyanotic or sometimes clammy skin, (d) The skin and tendon reflexes 
are abolished in the limb at first; the skin reflexes usually return 
later. The sphincters are almost always intact and sensation is very 
rarely affected. True trophic changes are almost unknown. 

3. Stationary, Chronic, Residual Stage. — Some improvement may 
occur, but this stage is generally marked (a) by accentuation of mus- 
cular atrophy, connective and sometimes adipose tissue replacing the 
contractile substance; it is most marked in the legs in old cases, and 
involves also the nerves, arteries, and tendons, (b) The bones become 
thin, flexible, friable, arrested in development and therefore shorter, 
since the bone cortex wastes and its medulla becomes more spongy; 
scoliosis may result, (c) There may be pronounced vasomotor lividity. 
(d) In the joints, nodules may appear as in cerebral hemiplegia; the 
joint structures are relaxed, and the "flail joint" may develop with 
luxation or subluxation, (e) Contractures are due principally to the 
mechanical influence of the unopposed antagonist muscles on the 
posture of the joint; if all the muscles are paralyzed they sometimes 
result from static causes, as from standing or attempting to walk, i. e. y 
from neglect; trauma and malposition of the luxated joints or tendons 
may also cause contracture or actual deformity; the arm, the shoulder, 
wrist and fingers are usually flexed and the elbow usually escapes 
involvement. In the leg, deformity (pes equinovarus) is more common 
than in the arm. 

Diagnosis. — The initial vomiting, fever or convulsions are usually 
misinterpreted until the diffuse purely motor paralysis appears, and 
consequently, the physician is unjustly blamed for what he cannot 
anticipate. The age, acute paralysis, rapid atrophy, reaction of degen- 
eration and loss of reflexes are positive diagnostics, together with the 
absence of sensory and sphincter disturbance. Bedsores "practically 
never develop." 

Differentiation. — (a) The various forms of muscular atrophy in 
children are gradual in onset, progressive, symmetrical, and often 
familial. The atrophy precedes and exceeds paralysis, and there is no 
arrest in development. The neural progressive muscular atrophy of 
Hoffmann, due to disease of the nerves or nerve roots, may produce 
paralysis, atrophy and the reaction of degeneration, but the affection is 
progressive, familial and involves sensation, (b) Birth palsies are 
distinguishable by their history, and more favorable course, (c) Mul- 
tiple neuritis (q.v.) has several distinctive features. Poliomyelitis is due 
to a local inflammation, is unilateral and spinal in type — or if bilateral, 
it is asymmetrical. Multiple neuritis is hematogenous and toxic, and 
therefore affects the spinal, and often the cranial nerves symmetrically 
and bilaterally, and usually involves the arms and legs: ataxia, sensory 



1100 DISEASES OF THE NERVOUS SYSTEM 

disturbance and local tenderness over the nerve trunks are common, 
its onset is more subacute and convulsions are rare; the reaction of 
degeneration is less intense and the issue is much more favorable. 

(d) The cerebral 'palsies of children (q. v. for table) affect the upper 
motor neurone and therefore never produce marked degenerative 
atrophy, or loss of faradic irritability. Its hemiplegic form involves 
the face and its paraplegic form is spastic. Disturbance of the intellect, 
focal or general convulsions and hemichorea are common. In rare 
cases, the cerebral and spinal forms of infantile paralysis may co-exist. 

(e) Myelitis also begins acutely, but usually in older subjects. Polio- 
myelitis may be confused only when it is bilateral, located in the cer- 
vical or lumbar enlargement, when sensory changes occur (2 per cent.), 
when the sphincters are involved or when the poliomyelitis reaches 
back into the white matter, producing a flaccid atrophic paralysis of 
an arm and a spastic paresis of the leg, the latter of which is only 
transitory. Bed-sores, which are common in myelitis, are "almost 
unknown" in poliomyelitis. (/) Painful affections causing immobility 
of a joint, hip-joint disease, Parrot's syphilitic pseudoparalysis and 
infantile scurvy bear a superficial resemblance to poliomyelitis. Dif- 
ferentiation is easy. Westphal noted that in the new-born the electrical 
reaction normally resembles that of the reaction of degeneration. 
(g) Hysterical contractures, sometimes with atrophy, disappear 
under anaesthesia and show no reaction of degeneration. 

Prognosis. — (1) Regarding life; there is little danger after the 
fever subsides; life is very rarely threatened from extension to the 
medulla oblongata. In exceptional cases, death may result from 
antecedent pneumonia. (2) Regarding relapses; second attacks 
almost never occur. (3) Regarding recovery; improvement is the 
rule. The diffuse initial paralysis usually becomes localized, but 
complete recovery is so infrequent that it may be disregarded. A 
localized initial paralysis may show but little improvement, and an 
extensive initial paralysis may diminish greatly. A definite prognosis 
of the ultimate extent of the paralysis cannot be made for two weeks 
and then only by the electrical examination. Muscles which show 
no reaction of degeneration after fourteen days will probably recover; 
those showing slight loss of faradic irritability will recover in great 
part; after six weeks only those muscles are paralyzed which will 
remain paralyzed; if there is no recovery in three months, there will 
be none or it will be slight. 

Treatment. — In the acute stage rest, a light diet, laxatives, diaphor- 
etics and diuretics are indicated. After the fever, the patient should 
be kept in bed for weeks, and should be given luke warm baths. 
Electricity is contra-indicated. As the paralysis begins to recede, a 
fuller diet and careful passive movements are beneficial. In the 
chronic stationary stage, with its inevitable and permanent paralysis, 
fresh air and liberal nourishment are important. Proof is lacking 
that strychnine is valuable, but it probably is because of its general 
tonic action, and its almost specific physiological action on the motor 



SUBACUTE AXD CHROXIC POLIOMYELITIS 1101 

elements of the cord. It should be given three or four weeks after the 
paralysis becomes stationary. Full doses may induce muscular 
spasm, pain and irritating paresthesia. Electricity cannot restore 
totally destroyed tissue, but it hastens recovery in partial lesions; if 
applied to the spine, it is useless, but the constant stream to the muscles 
and the faradic current to the skin are helpful. Contractures may be 
modified as well as deformities due to neglect, to which gymnastic 
movements, massage and orthopedic apparatus are essential. The 
child should be kept in bed for a long period. In some cases tenotomy, 
arthrodesis and tendon transplantation, by attaching the tendons of 
sound muscles to those of paralyzed muscles (Vulpius, Nicolodoni) 
are indicated. Nerve transplantation is in its infancy, but is proving 
very successful. 



V. Acute Poliomyelitis in Adults. 

This is rare in comparison with the infantile form. It was estab- 
lished by Vogt in 1858, Moritz Meyer, in 1861, and anatomically by 
Gombault, in 1873. The etiology is practically the same as that of the 
infantile variety; most cases occur between the twentieth and thirtieth 
years. The symptoms and course are essentially the same, with the 
following variations: fever is almost always present, which with the 
prodromes lasts longer than in children ; it often lasts a week. There 
is the same flaccid paralysis with atrophy and the reaction of degenera- 
tion, but it regresses less and results less frequently in contractures. 
The types of Remak are more clearly developed in the adult. Pain is 
a more prominent symptom. Friedlander observed mixed cases in 
which there was early although transient anaesthesia. Though the 
diagnosis is easy in children, it is more uncertain in adults, chiefly 
because multiple neuritis and to a lesser degree myelitis and hsemato- 
myelia are more difficult to exclude but in all three affections sensory 
alterations are usual. 



VI. Subacute and Chronic Poliomyelitis. 

Many reported cases are probably multiple neuritis, although 
Oppenheim has published perfectly clear cases. Etiology. — Metallic 
poisons and syphilis are important factors. Pathologically, two main 
types are distinguished; in the larger group there is no inflammation, 
but rathei a seemingly primary atrophy of the ganglionic cells, which 
heightens its resemblance to spinal progressive muscular atrophy, 
than which, however, it runs a more rapid course; in a smaller group 
of cases there is early perivascular exudation in the anterior horn and 
later sclerosis, wherein it resembles acute poliomyelitis, although it is 
slower in its course. The anterior roots are involved and in most 
cases there is degeneration in both pyramidal tracts, possibly also in 



1102 DISEASES OF THE XERYOUS SYSTEM 

the posterior columns or roots, in Clarke's columns or rarely in the 
medulla. The course is gradual, for one extremity becomes slowly 
affected (in one to three years), sometimes with extension to others 
after months or years. There is paresis with atrophy, fibrillary tremors, 
partial or complete reaction of degeneration, decrease or absence of 
the reflexes and normal sensation and sphincters. Life is rarely 
immediately threatened, but recovery is most unlikely; if it occurs, 
neuritis, not poliomyelitis, is probably the actual lesion. The ultimate 
outcome is unfavorable. Differentiation is, as follows: (a) Multiple 
neuritis (see Acute Poliomyelitis); (b) from progressive spinal 
muscular atrophy, even an anatomical differentiation is not easily 
made. As a rule, the following clinical distinctions hold; in progres- 
sive muscular atrophy, atrophy precedes and exceeds the muscular 
weakness, fiber after fiber of muscle very slowly wastes, the atrophy 
is especially marked in the distal parts as in the hands and fingers, 
and the reaction of degeneration is usually less complete. In chronic 
poliomyelitis, atrophy always rapidly follows paralysis; it is an out- 
right atrophy {atropine en masse), it occurs more often in the proximal 
parts, as in the shoulder, and the reaction of degeneration is marked. 
(c) In amyotrophic lateral sclerosis the paralysis is spastic with in- 
creased reflexes, contractures and often with bulbar symptoms. 
Treatment is the same as that of the chronic stage of acute poliomye- 
litis. 

VII. Landry's Paralysis. 

Landry's paralysis (acute ascending or centripetal paralysis) was 
described by Landry and independently by Kussmaul in 1859. 
Landry's description included five cases of his own and five others; 
the famous Cuvier died of this disease, in 1832. Acute ascending 
paralysis is a symptom complex rather than a disease in itself and 
may be conveniently classified under inflammatory affections of the 
cord. The etiology is vague. The affection occurs mostly between 
twenty and forty years of age and three times more frequently in males 
than in females. It has followed acute infections, as diphtheria, 
typhoid, influenza or variola and also chronic infections as syphilis 
and tuberculosis. 

Pathology. — In the early and in many recent cases no anatomical 
findings existed, and on this Westphal (1876) founded his three 
criteria: (a) that the disease is a progressive, ascending and finally 
fatal affection with (b) normal electrical reaction and (c) negative 
findings at autopsy. Though negative findings are frequent, recent 
cases have given definite though varying postmortem results, as 
structureless exudation in the cord, disseminated foci of inflam- 
mation in the cord, medulla and pons, changes in the pyramidal 
tracts, anterior horns and in the spinal and sometimes in the cerebral 
peripheral nerves. By some writers two forms are distinguished: 
(a) the bulbar or medullary form, in which sensation and electrical re- 



MULTIPLE SCLEROSIS 1103 

actions are normal, and (6) the peripheral neuritic form, with sensory 
and electrical alteration. The parenchymatous swelling of the liver, 
spleen, kidneys and lymphatics indicates a general infection or tox- 
aemia. Bacteriologically, an anthrax-like bacillus (Baumgarten), the 
pneumococcus, typhoid bacillus, bacilli in all the peripheral nerves 
and streptococci ((Ettinger and Marinesco) have been found. 

Symptoms.— The onset is acute with short prodromes, as head- 
and back-ache, muscular spasms, and paresthesia, or it is without 
prodromes. Paralysis usually commences in one foot, then in the 
other, and develops in the legs, thighs, abdomen, back, arms, even in 
the face or the eyes, possibly with optic neuritis; the paralysis is pro- 
gressive and ascending; when the medulla is invaded, dysarthria, 
dysphagia and paralysis of the tongue occur and finally death results 
by respiratory paralysis or in atypical cases by circulatory paralysis. 
The proximal parts of the limbs are more involved than the distal and 
some muscles may be unaffected. Fever is usually absent; the sen- 
sorium, sensation, sphincters and electrical reaction are usually normal. 
There are no tremors, no twitchings, no convulsions, no contractures, 
no trophic disturbance. The reflexes are variable, but are usually 
decreased or absent. In rare cases there may be partial reaction of 
degeneration (which usually has not time to develop), atrophy, and 
moderate disturbance of sensation or the sphincters. The paralysis 
may be of the descending type, in which event the bulbar involvement 
is fatal before the paralysis in the legs is well developed. 

Course and Prognosis. — The disease lasts two or three days to one 
or two weeks, and usually terminates with a respiratory paralysis. 
Bulbar symptoms are ominous, but not necessarily fatal. The central 
form of paralysis is fatal and the peripheral form probably includes 
most of the recoveries. In rare cases, death may occur in a few hours 
or only after months, with remissions and exacerbations. In the 
still rarer cases of recovery, chronic paralysis of some part may re- 
main. If recovery ensue, the paralysis regresses in an order inverse to 
that of development. A diagnosis is usually easily made, because of 
the ascending motor paralysis with loss of reflexes and without marked 
mental, sensory, sphincter or electrical alteration. The treatment is 
that of myelitis or multiple neuritis. Administration of strychnia and 
other stimulation is indicated if the bulbar symptoms are manifested. 
C. L. Greene reports a case which was kept alive by artificial respira- 
tion forty-one days after respiratory failure set in; he advises calomel, 
colonic flushings and oxygen inhalations. 



MULTIPLE SCLEROSIS. 

Insular or disseminated sclerosis, sclerose en plaques disscminecs, was 
described pathologically by Cruveilhier and Carswell (1838); Frerichs, 
in 1849, made the first diagnosis, and Charcot (and Vulpian),in 1863-64, 
gave a description of the typical case. 



1104 DISEASES OF THE XERYOUS SYSTEM 

Etiology. — In fully 50 per cent, of the cases no cause is found, and 
little is known of its etiology. It occurs equally in either sex and 
usually commences between the twentieth and thirtieth years. Cases 
resembling multiple sclerosis (pseudosclerosis) occurring after the 
fortieth year are thought to be arteriosclerotic. Two main factors are 
thought to exist: (a) Acute infections, as typhoid, pneumonia, measles, 
smallpox, etc. Marie adopted this theory, but Oppenheim finds that 
many cases can be traced back to infancy, a view vigorously contested 
by Strumpell as is (b) the idea that chronic intoxications with alcohol, 
lead, etc., are causal. 

Pathology. — Macroscopically, the sclerotic foci are usually seen 
with ease as irregular grayish-red areas as large as a pea or walnut; 
they are multiple (numbering even over 100), are distributed at 
random and occur largely in the white substance, although recent 
studies by Oppenheim and Taylor have revealed equal involvement 
of the gray matter. In most cases their distribution is cerebrospinal, 
in rarer cases in the cord alone, and most rarely in the brain only; 
the brain cortex is less frequently involved than the centrum ovale, 
central ganglia, corpus callosum, and the anterior under surface of the 
pons and the crus. The medulla is quite often and the cerebellum 
rarely involved. The white matter in the cord is more frequently 
affected than in the brain. On section, the focus is a trifle sunken and 
transparent, is fairly well demarked, firm save in the freshest foci, and 
on hardening in Muller's solution, appears light green, while the nor- 
mal tissue is a darker green color. Microscopically, the medullary 
sheaths in the white substance are thinner or absent and though the 
axis cylinders are somewhat wasted and at times varicose, their re- 
markable persistence, first noticed by Charcot, causes the incomplete 
character of the symptoms and the usual absence of ascending and 
descending degenerations. The ganglion cells suffer some atrophy 
and pigmentation, though in general they resist the sclerosis fairly 
well. The foci stain deeply with carmine, are not sharply demarked 
from the healthy tissue and show corpora amylacea, granule-bearing 
cells, increase of the fine meshed neuroglia fibrils, nuclear proliferation 
and sometimes Deiter's cells. In contrast with the system-degenera- 
tions, the primary change is interstitial with secondary changes in the 
nervous tissue. Some pathologists, as Ribbert, see significant changes 
in the bloodvessels of early cases, as arterial thrombosis, followed by 
exudation, and finally neurogliar proliferation; this theory is vigor- 
ously opposed by Strumpell. The cerebral nerves suffer often, 
especially the optic nerve, in which proliferation of connective tissue 
is followed by loss of the medullary sheaths, while the axis cylinders 
are unaffected. The nuclei, roots and nerve trunks of the third, eighth, 
seventh and other cranial nerves may suffer similar alteration. The 
spinal nerve roots are not infrequently involved; the peripheral 
nerves have not been systematically studied. 

Symptoms. — The clinical picture is so variable that a definite 
description cannot be made to cover all cases. Charcot's description 



MULTIPLE SCLEROSIS 1105 

included the intention tremor, the nystagmus, scanning speech, motor 
weakness and rigidity, and apoplectic insults, although he recognized 
atypical forms (formes frustes). 

1. Motor Symptoms. — These are the most important, (a) Mus- 
cular weakness is very common. Paresis is more frequent than paraly- 
sis, and the gross muscular power is lessened, though rarely abolished, 
since some axis cylinders remain intact. The movements are slow 
and fatigue rapidly follows their repetition; this statement applies to 
isolated rather than to synergistic movements. The paresis is most 
apparent in the legs, there is usually some in the arms, and frequently 
some in the musculature of the eyes, head and speech. It sometimes 
does not develop until late in the disease, may at no time be conspicu- 
ous, and is commonly associated with increased reflexes and spasticity. 
The gait is spastic, scuffling, and the feet seem to stick to the ground; 
to this is sometimes added a cerebellar, atactic or paretic element. 
Muscular atrophy is rare but may result from an adventitious focus 
in the anterior horn. The electrical reactions are practically normal. 
(6) Muscular rigidity is the most frequent finding, is referred to 
disease of the lateral columns and is most developed in the legs. It 
increases with successive movements ; for example, each step becomes 
more stiff in walking. It is sometimes slight in degree, and amounts 
only to a sense of stiffness; in other cases the spasticity is so extreme, 
and the muscles so hard that the limb cannot be moved even with 
great effort. Contractures develop, which usually affect the adductors 
and extensors first and the flexors later, and draw the heels up to the 
buttocks. Contractures often affect the muscles of the neck, (c) 
Tremor is one of the most striking phases of the disease, being present 
in 75 per cent, of cases. It is caused as is the paresis, by the loss of the 
medullary sheaths (Charcot) which allows diffusion of nerve impulses, 
by foci in the pons or thalamus (Erb), or by lack of coordination 
between antagonistic muscles (Striimpell, v. Leyden); the axis cylinders 
remain intact. There is no tremor during rest, but it appears when 
voluntary efforts are attempted, whence the name intention tremor; 
it develops as the patient reaches for an object, which is grasped 
only after jerking and unsuccessful efforts. The hand carrying a 
glass of water to the mouth shakes so much that all the water may be 
spilled by the rhythmic tremor, which possesses a wide range, and 
occurs five or six times to the second. It is apparent in the head when 
the patient sits, because the muscles of the neck are in constant action 
to support the head; it disappears in the recumbent posture. Similar 
tremor occurs in the face, larynx, trunk or legs on changing posture, as 
rising; in the fingers, it produces handwriting which becomes more 
erratic with each word written; and in the thoracic muscles, it causes a 
species of cog-wheel respiration, (d) Nystagmus occurs in 50 per cent, 
of cases, and is elicited by having the patient follow with his eyes 
the index finger when moved to one side of his field of vision, his head 
remaining stationary. His eyes show short, jerking lateral movements. 
It is most common on lateral or vertical movements. Spontaneous 

70 



1106 DISEASES OF THE NERVOUS SYSTEM 

nystagmus is rarer, as nystagmus on attempting to focus the eyes. It 
must be remembered that it may occur without organic disease, as in 
general weakness or convalescence. There is no satisfactory explana- 
tion; it is considered a tremor or an incoordination, (e) The speech is 
scanning (54 per cent.) syllabic or staccato; it is slow, monotonous, 
unmodulated and sometimes explosive, especially for the letters c, p, g 
and d. The speech muscles become fatigued easily and the end of a 
sentence is often elided; the sounds are often nasal, interrupted by 
yawning inspiration, or by expiration at the beginning of each syllable. 
Leube observed a tremor of the vocal cords, which oscillated during 
their movement. The cause of the peculiar speech is not clear; it may 
be due to tremor, or ataxia from foci in the pons or medulla. (/) 
Paresis of the eye muscles (in 17 per cent. Uhthoff) affects the third or 
sixth nerves, convergence or associated movements. About 50 per cent, 
is nuclear. In rare cases the paralysis is progressive. Transient 
diplopia, unequal pupils, rhythmic spontaneous widening and narrow- 
ing of the pupils (hippus) and strabismus are less common, (g) 
Apoplectiform seizures (in 20 per cent.) develop without prodromes, 
and are marked by partial, rarely by complete coma, increased pulse, 
high temperature, aphasia and hemiplegia, which is usually fugitive 
and flaccid, rarely enduring or spastic. They may recur. In most 
cases negative pathological findings exist, but Leube and Leyden refer 
them to acute encephalomyelitis. Though usually hemiplegic, they 
may exceptionally produce paraplegia, hemiansesthesia or ataxia, 
or monoplegia. Less frequently, unilateral convulsions occur. 

2. Sensory Symptoms. — These are less frequent (30 per cent.) and 
important, because the sensory fibers are more resistant to disease, 
although they are rarely wholly absent. Freud found sensory symp- 
toms in 80 per cent, of his cases. Subjectively, dull pains, formication, 
vertigo, the importance of which is ''frequently overestimated," and 
paroxysmal moderate headache are frequent, and lightning pains, 
crises, girdle sensation, trigeminal neuralgia, palpitation and dyspnoea 
are very uncommon. Objectively, any species of sensation may be 
involved, especially in distal parts of the extremities, where it is usually 
transient. Ataxia is usually referred to disease of the posterior columns 
or sensory tracts of the pons or medulla; it is marked in 50 per cent, 
of cases and may produce a typical tumbling cerebellar gait. 

3. Special Senses. — The optic nerve is affected in 45 per cent., 
usually as a pallid partial atrophy involving its temporal side, and less 
often as neuritis or complete atrophy with total blindness. The change 
is more conspicuous pathologically than clinically. Optic neuritis is 
transient and runs a rapid course; in the majority (60 per cent.) of 
cases, it produces central scotomata, although at times it narrows the 
field of vision. It may be the first sign of the disease. Hearing and 
taste may be affected. 

4. Psychical Symptoms. — Slight mental impairment is common; 
the patient is indifferent and singularly complacent; the memory is 
weak; psychoses are rare. Compulsory or forced laughing and weep- 



MULTIPLE SCLEROSIS 1107 

ing are partly without motive and partly emotional ; they are sometimes 
referred to mental alteration but probably should be classed among the 
motor symptoms and be referred like the analogous compulsory yawn- 
ing or swallowing to lesions in the medulla, pons or crus. 

5. Bulbar Symptoms. — These may, in rare cases, resemble the 
symptoms of bulbar palsy, as dysphagia, anarthria, and tongue atrophy. 

6. Reflexes. — The tendon reflexes are increased, most markedly in 
the legs. The patellars are exaggerated, there is ankle clonus, and 
tickling of the sole produces dorsal flexion instead of the normal plantar 
flexion of the foot (Babinsky's sign) showing disease of the pyramidal 
tracts. The skin reflexes are usually said to be normaL, but Strumpell 
found the abdominal reflexes absent in 70 per cent, of his cases. The 
pupillary reflexes are usually normal or but slightly slow. 

7. Sphincters. — Lasting or severe symptoms in the bladder or rectum 
are uncommon, though slight disturbance and weakness occur in most 
cases. The bladder is often hypertonic and irritation is frequent. The 
sexual power is variable. 

8. Trophic Symptoms. — These are rare; they consist of skin erup- 
tions, oedema, low temperature, sweating, chronic arthritis and ery- 
thromelalgia. 

Course and Prognosis. — The onset is usually gradual; the spinal 
symptoms are most prominent and in most cases the weakness in the 
legs appears first and for a long time is hard to interpret; it occurs 
without pronounced sensory symptoms, bladder disorder or atrophy. 
Sometimes the onset is acute, with loss of consciousness, transient 
hemiplegia, vertigo, headache, eye symptoms, vomiting and optic 
neuritis. In the average case the leg paralysis is followed by scanning 
speech, nystagmus, and tremor, which covers a chronic course averag- 
ing three to six, or in some cases even more than twenty years. A 
rapid course, as twenty-three months, may occur in the bulbar form. 
The symptoms remit and recur. Progression to a fatal ending is 
inevitable. Charcot distinguished three stages (a) the period from the 
development of the first symptoms to the tremor and paresis, (b) the 
period in which the patient is bed-ridden, and (c) the terminal stage with 
dementia, decubitus, sphincter paralysis, cystitis and septicopyemia. 

Diagnosis. — The typical case is unmistakable, because of the cardi- 
nal symptoms, which consist of (1) intention tremor; (2) spastic 
paresis; (3) nystagmus; (4) scanning speech; (5) ataxia; (6) 
increased reflexes; (7) optic atrophy; (8) the slow, uneven course 
with remissions and recurrences; (9) the variability of the symptoms; 
(10) apoplectic insults; and (11) moderate involvement of the mental- 
ity, sensation, bladder and rectum. 

Differentiation. — Transient hemiplegia may suggest hemorrhage, 
syphilitic thrombosis, embolism or tumor (q.v.). If these can be 
excluded, multiple sclerosis or paretic dementia must be differentiated 
(q.v.). Paralysis agitans is usually but rather unnecessarily differen- 
tiated; the absence of the cardinal signs of sclerosis multiplex and the 
presence of a constant fine tremor of the hands and fingers (not of the 



1108 DISEASES OF THE NERVOUS SYSTEM 

large joints, and much less in the head) which is not increased by move- 
ment, its persistence during rest, the mask-like facies, festinating 
speech, peculiar attitude, gait, propulsion, retropulsion, muscular 
rigidity without increased reflexes, and the advanced age are clear and 
characteristic points. 

Multiple Sclerosis. vs. Syphilis. 

Occurs in the medullary substance. Occurs in the periphery of the cord 

(meningomyelitis and root symp- 
toms). 

A focal disease. Diffuse. 

Nystagmus, scanning speech, tremor. More frequent mental obscuration, in- 

sults, hemiplegia, etc.; speech may 
be disturbed or slow in pons lesions 
but is not scanning. 

Transitory amaurosis, hemianopsia, Amaurosis, etc., are frequent, 

complete optic atrophy, choked disk 
or neuritis are very rare. 

Partial optic atrophy occurs. There is more disturbance of vision. 

Mydriasis 1 per cent., myosis 4 per cent. Mydriasis is very common. 
Argyll-Robertson pupil practically 
never present. 

Cortical symptoms may be present; 
rectum and bladder more frequently 
involved; results may be obtained 
in early stages from antisyphilitic 
remedies. 

Hysteria more than any other disease simulates early multiple 
sclerosis, the two affections often occur together, and in both the 
symptoms are changeable. In hysteria sensory symptoms are much 
more prominent, there is often limitation of the visual fields, monocular 
diplopia, contractures, and convulsions, but there is no optic atrophy, 
nystagmus is extremely rare (Sougues) as is the scanning speech; and 
intention tremor may occur, but is not so wide. The movements in 
hysteria are often accompanied by contraction of the antagonist 
muscles, which is a most valuable diagnostic aid. In extremely rare 
cases, described first by Westphal as pseudosclerosis, similar symp- 
toms prevail though the autopsy shows nothing; the tremor affects 
the arms chiefly; there is no ataxia or nystagmus; the facies is some- 
what rigid and outbursts of anger are frequent; syphilis is a possible 
cause. Birth palsies may be accompanied by jerky movements, 
incoordination of the legs and even scanning speech, but the history of 
very early onset is conclusive. 

Strumpell groups the atypical forms as (a) the latent group; (b) 
those resembling chronic myelitis, or (c) pure spinal spastic paralysis, 
maybe resembling amyotrophic lateral sclerosis if the anterior horns 
are involved, or chronic bulbar palsy if the medulla is affected; optic 



SYRINGOMYELIA 1109 

atrophy in such cases indicates multiple sclerosis, (d) Cases resemb- 
ling tabes with ataxia, and pains, which are probably cases of com- 
bined system disease (v. i.); (e) the hemiplegic form; and (/) the 
psychical form. 

Treatment. — Treatment is futile. Drugs as silver and arsenic are 
inert, and hydro- and electro-therapeutic measures are useless. The 
patient should live in a warm climate during the winter months. 



(H). SYRINGOMYELIA. 

The term refers to cavities in the cord, and was first employed by 
Ollivier (1824). The affection was first described by Morgagni. 
Syringomyelia must be distinguished from hydro myelus (hydrorrhachis 
interna), which is a dilatation of the central canal due to develop- 
mental anomalies, possibly to stasis of cerebrospinal fluid resulting 
from pressure; it is usually an accidental finding at necropsy, or if 
symptoms are present they are those of syringomyelia. 

Etiology. — Sixty-three per cent, of cases occur between the tenth and 
thirtieth years and 70 per cent, of them in males. Other factors are 
wholly uncertain, as trauma, manual occupations, or cold. 

Pathology and Pathogenesis. — Gross Pathology. — A cavity may 
be seen from without. The cord is often lax, sometimes fluctuating or 
flat. The cavity is usually localized but may sometimes extend from 
the medulla to the filum terminale; it is most often found in the lower 
cervical or upper dorsal regions, less frequently in the dorso-lumbar 
segments or in the lower brain; in size it ranges from a narrow slit to 
a cavity as wide as the cord itself; it is not absolutely symmetrical and 
may be unilateral; it may communicate with the central canal, may be 
multilocular from septa or strands of tissue, and diverticula may be 
found. Its wall is smooth, sometimes pigmented from old hemor- 
rhages. Sometimes the cord is normal, but it usually suffers thickening, 
and sclerosis develops from the ependyma, posterior commissure or 
posterior horns, in the form of hard or soft, tumor-like, somewhat 
asymmetrical neurogliar proliferations, especially in the cervical 
region; these later break down and form secondary cavities. The 
posterior horns and columns are often affected, the anterior horns and 
columns less frequently and the lateral columns very rarely. Hemor- 
rhage into the gliomatous tissue or the cavity may result from rupture of 
the new formed bloodvessels. 

Minute Pathology. — The essential finding is overgrowth of the 
neuroglia, which in part breaks down and forms cavities. This hyper- 
plasia is most probably due to some congenital anomaly, which also 
explains its frequent association with dilatation of the central canal 
(hydromyelus). The neurogliar overgrowth is rich in fibers, whereas 
the ordinary glioma (gliomatosis) especially abounds in cells; syringo- 
myelia and gliomatosis may co-exist. The proliferation is seemingly 
embryonic in character, contains some large sharply nucleated cells, 



1110 DISEASES OF THE XERYOUS SYSTEM 



here and there a few epithelial cells, is firm as a whole, but somewhat 
softer towards the posterior horns, is often hyaline nearest the cavity 
from compression, and abounds in bloodvessels, which are often 
hard and hyaline. The cavity is usually lined with cylindrical epithe- 
lium like that of the central canal, sometimes only with neuroglia; its 
contents resembles cerebrospinal fluid, but is occasionally blood 
tinged or less often gelatinous, mucoid or milky. Degenerations occur 
in parts actually involved and at times in distant parts as in the medulla. 
The nerve fibers are not much involved, although secondary degenera- 
tion may occur in the posterior and less frequently in the lateral 
columns. 

The exact pathogenesis is obscure. Congenital hydromyelus (with 
primary neurogliar hyperplasia and secondary cavity formation), 
inflammation and hemorrhage are not causal factors. 

Symptoms. — There are three cardinal symptoms. (1) Partial or 
dissociated anaesthesia occurs in the typical case, in which the sensation 
of touch, pressure and locality is preserved while heat or cold and pain 
are not recognized as such but as simple pressure. Thermo-ancesthesia 
usually concerns perception of both heat and cold, sometimes of only 
one of them, or one in one place and the other in another; analgesia 
is frequently preceded by hyperalgesia; it concerns the superficial or 
deeper structures and usually corresponds with the thermo-ansesthesia 
which however may exist alone. Thermo-ansesthesia and analgesia 
usually begin in the hands and fingers and are later found on the upper 
trunk; sometimes the entire trunk, the legs, mucous membranes, and 
face may be affected, depending on the location of the cavity. The 
patient may suffer burns or injuries in these parts without pain. Dis- 
sociated anaesthesia is most probably caused by disturbance of con- 
duction of temperature and pain in the gray substance of the cord, 
which is frequently invaded by neurogliar proliferation and the cavity 
formation; tactile sensation traverses the white columns. In some 
cases the partial anaesthesia is unilateral. Anaesthesia may involve all 
variaties of sensation. Subjective sensory disturbances include 
paresthesia and burning, tabes-like pain in the neck, arms or trunk, 
and sometimes in the joints, spine or legs. 

2. Muscular atrophy is due to involvement of the anterior horn 
and affects the arms mostly, because the disease is largely in the lower 
cervical and upper dorsal cord. It is slow in onset, more marked 
than the attendant flaccid paresis, degenerative, and often observed 
with fibrillary muscular contractions and increased myotatic irrita- 
bility. It usually involves the small muscles of the hand as the inter- 
ossei, produces flattening of the thenar and hypothenar eminences and 
the claw-like hand as seen in the Duchenne-Aran type. The radial 
supply is first affected, then the ulnar and median supply. Sometimes 
the scapulohumeral type is observed, especially with bulbar symptoms. 
The muscles of the trunk, and much less often of the legs, may be af- 
fected. From cervical compression of the pyramidal tracts, paraplegia 
results, with increased reflexes and spasticity, in 12 per cent, of 






5 YRINGOM TELIA 1111 

eases. Other motor symptoms occasionally occur, as tremor, con- 
tractures, spasms, opisthotonos or choreiform movements. The gait 
is normal, spastic and paretic or sometimes of the cerebellar type. 
Romberg's sign and ataxia result from involvement of the posterior 
columns or coincident tabes. 

3. Trophic, secretory, or vasomotor symptoms may occur. Trophic 
symptoms are quite frequent. (a) Phlegmons and felons develop, 
particularly on the fingers. They are painless, chronic, often recurrent, 
and lead to necrosis of the bone, ankylosis of the joints, and to con- 
siderable deformity or mutilation, (b) The joints suffer in over 10 
per cent., especially in males (75 per cent.), and this is probably due 
to loss of articular sensation (whereby the joints are used inappro- 
priately) or to lack of the nutritional reflex. These arthropathies are of 
the hypertrophic form, with thickening and bony formation, like 
arthritis deformans or of the atrophic form with relaxation of ligaments 
or flail joint. There is little exudation, no fever, no pain. On the 
whole, they are similar to the tabetic joints but are more chronic and 
more often involve the upper extremities (shoulder 32 per cent., elbow 
28 per cent., hand 16 per cent., hip 8 per cent., ankle 8 per cent., knee 
6 per cent.), (c) Painless bone necrosis and spontaneous fractures may 
occur late in the disease; moderate scoliosis is frequent, usually 
confined to the dorsal spine, sometimes with kyphosis. It is probably 
due to trophic vertebral changes or possibly to atrophy of the back 
muscles; perforating ulcer, thick, friable nails and clubbed fingers are 
less common. Morvan (1883) described an affection as paresie anal- 
gesique avec panaris, endemic in Brittany, which is clearly syringomy- 
elia. "Morvan's disease" is marked by trophic disorders, excessive or 
deficient secretion of sweat, oedema especially on the dorsum of the 
hands, erythema, urticaria, more rarely local asphyxia, and herpes 
zoster. 

There may be other symptoms, (a) The reflexes of the skin are 
usually normal, although the abdominal, cremasteric and plantar 
reflexes are sometimes increased; the tendon jerks are variable, being 
often decreased in the upper and increased in the lower extremities. 
(6) The sphincters are not involved, or may be only late in the disease. 
Retention of urine and constipation are more frequent than incon- 
tinence, (c) Bulbar or pontine symptoms are not infrequent, are usually 
unilateral, and appear in the later stages. They include facial hemi- 
atrophy or paresis, paresis of the tongue with atrophy, partial dysphagia, 
paresis of the palate (nasal speech), paralysis of the vocal cords, of the 
external branches of the spinal accessory nerve (trapezius paralysis) and 
trigeminus (sensory symptoms), eye paralyses (abducens), unequal 
pupils, nystagmus, tinnitus, salivation, apoplectiform attacks, polyuria, 
glycosuria and vagus symptoms (disturbed pulse or respiration, vomit- 
ing, and singultus). Complications include hysteria, paretic dementia, 
tabes, pachymeningitis, Graves' disease, and epilepsy. 

Diagnosis. — An almost positive diagnosis can be made from the 
three combined cardinal symptoms; (1) the dissociated anaesthesia 



1112 DISEASES OF THE NERVOUS SYSTEM 

(thermoanesthesia and analgesia with practically normal tactile 
sensation) is the earliest, most constant and widely distributed sign. 
Grasset has collected cases of twenty or more nervous diseases (func- 
tional, traumatic, neoplastic, specific) in which the dissociation of 
syringomyelia has been found; but it remains highly distinctive in 
conjunction with (2) muscular atrophy of the upper extremities with 
paresis and (3) trophic disorders, felons, arthopathies , and scoliosis; to 
which three cardinal manifestations may be added the spastic paresis 
of the legs and bladder symptoms. Besides the classical form, various 
varieties are described by Schlesinger; (a) the latent form, (b) the motor 
form, simulating amyotrophic lateral sclerosis, (c) the sensory type, 
possibly resembling hysteria, (d) the trophic and (e) the tabetic types. 

Differentiation. — Progressive spinal muscular atrophy and amyo- 
trophic lateral sclerosis may resemble syringomyelia with poorly 
developed sensory symptoms (Clarke and Gull, 1862) but they possess 
very few sensory signs, no anaesthesia, no trophic disturbance and 
bulbar symptoms are bilateral. Juvenile muscular dystrophy may be 
simulated in the scapulohumeral type of syringomyelia. Peripheral 
neuritis rarely produces dissociated anaethesia but all variations of 
sensation are disturbed; the distribution of the paralysis is peripheral, 
not spinal or segmental, and there is the reaction of degeneration; 
neuritis of the upper brachial plexus (Duchenne-Erb paralysis) pro- 
duces paralysis of the shoulder, arm and supinator longus, a combination 
not found in syringomyelia. Focal disease of the anterior and posterior 
gray substance, as multiple sclerosis, hemorrhage, or myelitis may 
simulate syringomyelia, but their course is less chronic and there is less 
trophic disorder. The signs of irritation produced by tumor of the cord 
are lacking. Located in the dorsolumbar region, syringomyelia may 
closely simulate tabes, from the lancinating pains, crises and ataxia, 
but the Argyll-Robertson pupil is lacking and the sensory impairment 
is typical. The anaesthetic form of leprosy has caused difficulty but its 
anaesthesia is peripheral, not spinal, in type; in the lesions of the skin, 
ulcers, and nasal secretions, the Henssen bacillus is often found; if 
there are no lesions in the skin, thickness and tenderness of the nerves 
indicate leprosy. 

Course and Prognosis. — The onset is very gradual and the course 
chronically progressive, for years or even for decades. When recog- 
nized, the affection is well advanced and recovery is impossible. The 
first symptoms are pain and dissociated anaesthesia, followed by 
atrophy and paresis, with trophic changes in the advanced course. 
Death occurs from intercurrent disease, cystopyelitis, septicaemia and 
bulbar complications. 

Treatment. — Treatment is unavailing, being confined to hygienic 
and symptomatic measures. The danger of self injury, as a result of 
the peculiar anaesthesia, should be borne in mind. 



TABES DORSALIS, LOCOMOTOR ATAXIA 1113 

I. SYSTEM DISEASES. 

These constitute a small group of very important diseases and involve 
structures or systems having a common function, thus differing from 
such indiscriminate or random disease as myelitis or multiple sclerosis. 
The essential change is a primary slow degeneration of the nerve 
elements, followed by secondary proliferation of connective tissue (sclero- 
sis). The pathogenesis of these degenerations is not clear, although 
hereditary weakness causing nutritional failure at a certain age (the 
familial form), and the selective action of toxins in the blood acting on 
certain nervous structures, have been thought causes. 

System Disease of the Sensory Tract. 

The sensory type of system disease is locomotor ataxia in which the 
peripheral sensory neurone is affected, in the posterior roots and 
columns, while the motor types are spastic paraplegia, involving the 
upper motor neurone (pyramidal tracts), and muscular atrophy due to 
lesions in the lower neurone (anterior horns and roots). 

Tabes Dorsalis, Locomotor Ataxia (Duchenne). 

Definition. — A disease characterized (a) etiologically, by syphilis; (b) 
pathologically by lesions in the posterior spinal roots and posterior 
columns, in the cutaneous and muscular sensory and also the cerebral 
nerves; and (c) clinically by incoordination (ataxia), sensory symp- 
toms (pains and defective sensation), loss of myotatic irritability (of 
the tendon reflexes), loss of the pupillary reflex to light and trophic 
disturbances. 

It is the best known and most frequent chronic disease of the cord. 
Horn in 1827 partly described the affection, although Todd in 1847 
gave the first accurate account, eliminated paralysis, and found the 
posterior columns diseased at autopsy. Stanley first (1840) referred 
the affection to the posterior columns and peripheral sensory nerves. 
Tiirck first examined the tissues microscopically and Romberg (1851), 
and especially Duchenne (1858), popularized the disease; it is still 
known in France as Duchenne's disease. 

Etiology. — Syphilis is the essential causal factor (Fournier and 
Erb) in 75 per cent. (Gowers), 90 per cent. (Erb and Striimpell), or 
100 per cent. (Mobius). In about 10 per cent, of cases the syphilitic 
history and stigmata are lacking, whence it is sometimes attributed to 
other causes, as trauma, heredity, concussion, exposure, toxins of 
soft chancres (Hitzig and Buzzard), and ergotism (Tiiczek); but it is 
most probable that these are only apparent or incidental factors and 
that syphilis is the sole cause. The following etiological data of tabes 
are practically those of syphilis; age, 50 per cent, in the thirtieth to 



1114 DISEASES OF THE NERVOUS SYSTEM 

fortieth year; 25 per cent, in the fortieth to fiftieth year; less than 
25 per cent, in the twentieth to thirtieth year (Gowers); cases may occur 
in persons over fifty, under twenty, or even ten years of age, the latter 
of which are probably due to hereditary syphilis. Forty-seven juvenile 
cases were collected by Hirtz (1905); of these, the parents in thirteen 
instances had syphilis, tabes or dementia. Sex : as in syphilis and paretic 
dementia, ten cases occur in males to one in females. Syphilis is more 
difficult to diagnosticate in women and more often runs a latent course. 
Like syphilis, tabes is sometimes familial; Xonne (1904) saw tabes in 
a mother and two daughters. It prevails largely in cities, and among 
the higher classes ("syphilization and civilization"). It is uncommon 
in the negro though Hecht has seen cases. The reason that syphilis is 
not considered causal by some is the fact that tabes does not occur 
during its florid or even its tertiary stage; tabes is meta- or para- 
syphilitic, a degenerative lesion occurring on an average six to twelve 
years after the chancre or even later. Dalous (1904) collected 21 cases 
with active syphilis. 

Pathology. — The gross changes are usually visible to the unaided 
eye; the posterior columns are smaller, outwardly flattened instead of 
rounded, and appear gray from loss of the medullary sheaths and trans- 
lucent from primary loss of nerve fibers and secondary increase of con- 
nective tissue. The pia may be secondarily opaque and thickened. 
The degenerated areas are somewhat sunken on section. The posterior 
horns and roots are always somewhat atrophied and gray or grayish- 
red in color. As to minute changes, the toxins (Striimpell) bring 
about a very slaw degeneration of the peripheral sensory neurone, its 
fibers, and the processes of the spinal ganglia cells, which themselves 
suffer much less and later obvious changes than their processes. These 
processes run in two directions : to the periphery and to the posterior 
roots and posterior columns, (a) The peripheral spinal sensory nerves 
are often degenerated (YYestphal, Pierret, Dejerine), less in large 
trunks (sciatic or crural nerves) than in the peripheral filaments of 
the skin, joints and muscles which are important in the sensory, trophic 
and atactic symptoms of tabes; their white substance wastes and then 
their axis cylinders. The trophic centres for these fibers are largely 
in the root-ganglion but there is some evidence that there are also 
some peripheral trophic cells, (b) The fibers running from the ganglia 
to the posterior roots are more early, regularly and obviously changed. 
In the cord the degenerated tracts stain deeply with carmine and 
include only structures derived from the posterior roots and their col- 
laterals, all others escaping involvement. The posterior root fibers 
run (i) to the posterior columns, whence there occurs, low down in the 
cord, degeneration in Burdach's and then higher up in GolPs columns, 
into which the root fibers are pushed as new and higher root fibers 
enter the cord. The location of the degenerated fibers therefore differs 
at successive levels and the degeneration is an ascending one. In the 
lumbar cord the posterior columns are most intensively and extensively 
diseased, especially in their middle and posterior parts, nearest the 



TABES DORSALIS, LOCOMOTOR ATAXIA 1115 

posterior roots and surface of the cord. Early and marked degener- 
ation is found in the fine fibers of Lissauer's zone which lies just back 
of the posterior horn. The anterior part of the post. ext. column and the 
central part of the post. int. column are slightly, if at all, diseased as 
they are not derived from the post, ganglia. In the dorsal cord the post, 
columns are degenerated save in the post. ext. part and in the ant. part. 
In the cervical cord the post. int. columns are diseased (representing the 
root fibers of the lumbodorsal cord) and also some areas in the post. ext. 
column where degenerated root fibers have just entered. There is 
some pathological as well as clinical variation in different cases ; Marie 
holds that one set of sensory fibers after another is involved, and that 
degeneration develops by segments. Tabetic changes are usually most 
developed in the lower cord, but in the rare "cervical tabes" the upper 
cord suffers severely and perhaps exclusively, (ii) From the post, 
roots a second series of fibers run to Clarke's column. They and their 
collaterals are degenerated but the cells of Clark's column (and their 
ascending fibers to the cerebellum) usually remain intact, (hi) The post, 
horns degenerate, because they contain fine root fibers, (iv) The reflex 
collaterals to the ant. horns also degenerate. 

As already stated, pronounced or early atrophy in the cells of the 
post, ganglia is rare. Degenerative changes may involve other analo- 
gous neurones, as the auditory, trigeminus, optic, visceral, sympathetic 
or ocular nerves, or less often the peripheral motor nerves, the pyra- 
midal tracts, the muscles themselves, the medulla and the brain cortex. 
In old cases, corpora amylacea are found. 

The exact pathogenesis is still disputed : (i) Obersteiner believes the 
initial changes are in the pia through which the dorsal nerve roots pass ; 
(ii) Marie contends that there is a lymphangitis of the post, columns; 
(iii) Edinger believes the toxins (admittedly those of syphilis) attack 
those nervous structures most in use, and therefore most easily fatigued ; 
these are the sensory tracts of the lumbar cord, pupil, bladder and 
intestine. 

Symptoms. — The symptoms vary chiefly as to their intensity, 
duration and order of succession. In general three stages are described. 
1. The initial, neuralgic or pre-atactic stage, lasting sometimes for years 
(usually 6 to 8, or even 10 to 20). The earliest symptoms are usually 
sensory and irritative, as pains which are either lancinating or rheu- 
matic, perhaps neuralgic or like migrane or paresthesia. The knee 
jerk is lost in nearly all cases, usually very early and the pupil reacts to 
accommodation but not to light. 2. These symptoms usually exist years 
before the ataxy of the second stage appears. Much less often optic 
atrophy, sexual, sphincter, ocular, articular or visceral symptoms first 
attract attention. The atactic stage may last many years; muscular 
movements become incoordinate, especially in the legs, but sometimes, 
though later, in the arms. The tabetic gait develops, the patient sways 
when his eyes are closed (Romberg's sign), sensation is obtunded, 
especially the muscular sense, urinary and sexual disorders develop 
and in some cases diplopia. The gross muscular power is unimpaired. 



1116 DISEASES OF THE NERVOUS SYSTEM 

Trophic, joint, bone and skin lesions and visceral disturbances (crises) 
occur. 3. The terminal stage, improperly called paralytic, is much like 
that of other chronic affections of the cord. The patient is bed-ridden, 
helpless from extreme ataxia and rarely from motor weakness, and bed- 
sores, lesions in the medulla, and cystitis lead to a fatal issue. 

Special Symptoms in Detail. — 1. Of the motor symptoms, (a) 
ataxia (incoordination) is of such importance that the disease is named 
locomotor ataxia. It is present in 75 to 88 per cent, of cases but may 
develop slowly, only after years or perhaps not at all; it is less common 
at the present time than formerly (Brissaud) ; itoccured in barely 10 per 
cent, of Babinsky's cases, who explains this decrease by his use of mer- 
cury. Ataxia is a disturbance of harmonic efficient muscular contrac- 
tion and arises not only from tabes but also from lesions in the upper 
sensory neurones of the cord, medulla, cerebellum, pons and cerebrum. 
The cause of tabetic ataxia is probably disease of the afferent muscular 
fibers (muscular anaesthesia, Reynolds 1855), intensified by sensory 
impairment, disturbance in the reflex collaterals and sometimes by atro- 
phy of the optic nerve. Duchenne first made the valuable distinction 
between ataxia and loss of muscular power which is preserved until late 
in the disease. Ataxia is frequently first observed by the patient when 
he walks in the dark or closes his eyes, as in washing the face. When 
he closes his eyes or looks well upward or when the heels and toes are 
brought closely together, the body sways (Romberg's sign) and he 
perhaps falls, because vision is one of the sensory factors in equili- 
bration. Later, incoordination occurs even when the eyes are open, 
and the patient can walk only with the support of a cane. It is often 
increased by removing the shoes, which support the feet. The ataxia 
is marked when the patient attempts to " about face," to walk back- 
ward (Althaus), to stand on his tiptoes (Rosenbach) or to stand with 
the knees half flexed (Brissaud). In women marked ataxia is less fre- 
quent than simple awkwardness. Ataxia is also seen when the patient, 
with the eyes closed, attempts to place his heel on the opposite knee, or 
perform with one limb those movements made by the physician in 
another limb. The gait is atactic, the feet are lifted too high, are thrown 
too far forward and outward {wide-legged gait) and are brought sud- 
denly and forcibly down in a "stamping" fashion. It has been called 
the "rooster gait." A tumbling cerebellar gait is less frequent, 
observed later in the disease and referable to involvement of the 
trunk or hips. Movement in tabetics is characterized by excessive 
excursion, rapidity, irregularity and uncertainty of execution. The 
arms usually escape or are involved less markedly and later, save in 
cervical or brachial tabes. The patient cannot execute finer move- 
ments, such as writing or buttoning the clothes. Ataxia is rare in the 
head, eyes, face and tongue, although in exceptional cases it has been 
observed in masticatory movements, (b) Muscular power may be 
normal even with the extreme ataxia. The muscles are hypotonic, and 
this loss of tone allows hyperextension and hyperflexion of the joints; 
it is due to loss of centripetal sensory conduction. There is a feeling of 



TABES DORSALIS, LOCOMOTOR ATAXIA 1117 

weakness in the legs in two-thirds of the cases. Attacks of transient 
muscular weakness are frequent (62 to 92 per cent.) as in the eye 
muscles. Paralysis, though usually transient, may be permanent from 
disease of the pyramidal tracts, ant. horns or peripheral nerves, (c) 
Atrophy is not common, but may affect the arm (type of Duchenne- 
Aran), the leg (the tabetic club foot, usually due to neuritis), or most 
rarely the face (hemiatrophy), (d) The electrical reactions are usually 
normal. Sometimes muscular contractures occur, due to abnormal 
sensation. Associated movements, in which one leg moves when its 
fellow moves, and spontaneous movements, taking place without 
volition or consciousness of them and due to the slight unnoticed 
reflexes, may occur. 

2. Sensory symptoms are prominent. In the majority of cases the 
disease begins with irritative sensory phenomena, (a) Spontaneous 
pains occur in 80 to 90 per cent., are sudden, paroxysmal, lightning-like, 
lancinating, and often nocturnal. They are usually severe, but may be 
agonizing, though sometimes only dull, burning or like those of 
muscular rheumatism; they may be increased by damp and cold. They 
last from a few hours to a day or two. The legs are the most common 
seat of pain, then the back, trunk, arms especially in the ulnar distri- 
bution, and sometimes the head (occipital nerves) and face (trigeminus, 
whose ascending branch represents the sensory parts of most of the 
other cranial nerves); Collet found migraine-like attacks in 40 per 
cent.; their bilateral occurrence is very suggestive. The pains are 
more often deep than superficial and are more often irregular than 
exactly conforming to a nerve's course. The pain in the trunk may 
assume the "girdle form" (31 per cent.) over a narrow or broad zone. 
Sometimes the area affected shows local trophic changes, as herpes, 
ecchymoses or friable hair, (b) Paresthesia? are common, as creeping 
sensations (formication), "pins and needles" sensations, a sense of 
heat or especially of cold. They occur in the legs in 66 per cent, of 
cases. If in the arms, the ulnar distribution is especially involved (17 
per cent.). The ulnars at the elbows are often insensitive to pressure 
(Biernacki's sign) and show lessened appreciation of pain, temperature 
and tactile impressions. In the face a perverted feeling, as of a mask, 
may be noted (''Hutchinson's mask"), (c) In the early stages hyper- 
esthesia (probably from nerve irritation) may be noted. In 86 per 
cent, of developed cases sensation is reduced; it is most often of the 
spinal or segmental type, though sometimes peripheral. Tactile 
sensation is often disturbed, especially in the legs and soles of the feet. 
Hypesthesia may be observed on the buttocks, scrotum, perineum, 
penis (the cause of early decreased sexual power) or on the trunk as a 
zone (80 per cent.) which is hypothetic especially to light touch (Hit- 
zig and Lahr). It is not usually found higher than the third rib, 
although there may be occasional occipital or trigeminal anesthesia. 
If the arms are affected, it is mostly in the hands and palms. Some- 
times a touch to one member is referred to another (allocheiria). 
Occasionally a single contact feels like several (polyaesthesia). 



1118 DISEASES OF THE XERVOUS SYSTEM 

Perception of pain is lessened in 30 to 70 per cent, of the cases, occurring 
alone or with hypsesthesia; a short stab with a pin is often felt merely 
as a touch. Pain conduction is often retarded (36, even 90 per cent, of 
cases) ; the sharp stick of a pin is felt at once as a touch, but the pain is 
perceived only after 7 to 15, even 35 seconds. When asked to state his 
sensations, the patient says "now" when stuck, and later "ouch" as 
he feels the pain. Analgesia may be the cause of severe injuries as in 
syringomyelia. Sometimes the testicles are insensitive to pressure, and 
inflammations such as pleurisy may run a painless course. The sense 
of temperature is rarely affected alone or completely and is usually 
associated with analgesia; tabetics are often oversensitive to cold. 
The muscle sense is disturbed not only as regards the location, but also 
as to active or passive movements of the muscles, especially of the legs. 
A change of angle of one or two degrees in the joints and tendons is 
noted by normal individuals, while in tabetics much wider movements 
are not perceived, especially those in the small distal joints; the toes 
may be moved unnoticed by the patient, perhaps in the later stages the 
fingers also. 

3. The reflexes are also involved, (a) The skin reflexes may be 
increased early in the disease. Later the plantar and gluteal reflexes 
are somewhat decreased. The abdominal and cremasteric may long 
remain normal, (b) Of the tendon reflexes, the knee jerk is lost early 
(JVestphaTs sign); this is a most constant finding in tabes (98 to 100 
per cent.) and is due to disease of the afferent nerves (and collateral 
reflex paths in the cord). These reflexes should be examined by having 
the patient sit on the edge of a table, with his eyes closed, and excluding 
cerebral inhibition of the reflexes by having him pull, in an outward 
direction, the locked fingers ( Jendrassik's reinforcement). The patellar 
reflexes are rarely present save in exceptional cases of cervical tabes. 
They are sometimes simulated by a reflex movement which occurs after 
tapping the patellar tendon but in this case the interval is longer before 
the reaction, and the same reaction may follow a simple pin prick. 
The knee jerk has been known to return after a cerebral hemiplegia. 
The Achilles reflex is often lost, though less frequently than the patellar 
(or equally frequently, according to Frankel). The tendon reflexes of 
the arms are sometimes decreased. 

4. The Eyes and Special Senses. — (a) The pupils contract to accommo- 
dation but not to light in 85 to 97 per cent. (Argyll-Robertson, 1869). 
In testing, the patient must look to a distance, and one eye must be 
tested at a time lest accommodation be confused with contraction to 
light. The cause of the Argyll-Robertson pupil is not known, but it 
may depend upon a degeneration of fibers connecting the optic nerve 
with the oculomotor muscles (see Progressive Paralysis of Insane). 
The tabetic pupil rarely dilates on pinching or sticking the skin of the 
neck (Erb), especially if the pupil is small. In about 50 per cent, it is 
small (spinal myosis) ; the pupils are often unequal in size and irregular 
in contour, (b) The eye muscles are affected in 40 to 50 per cent, of 
cases. Mobius holds that ocular paralyses are almost as important as 



TABES DORSALIS, LOCOMOTOR ATAXIA 1119 

the pupillary changes, especially when they are painless wherein they 
differ from the rheumatic and syphilitic forms; he holds that the 
majority of all eye paralyses in the adult are tabetic. Diplopia (in 16 
per cent.) is common and usually unilateral. The order of frequency 
of involvement is the sixth, third (lev. palpebrarum), sup. rectus and 
fourth nerves. When one muscle is paralyzed the others are usually 
weak, The early form of paralysis is usually transitory; the late form 
is often permanent. Nuclear degeneration is the most probable cause, 
(c) Optic atrophy (10 per cent.) is generally an early symptom. The 
disk is pale and shrunken, especially on its temporal side and at the 
edges, which are sharp. The process is always bilateral; central 
scotoma and actual neuritis are rare. The process is usually progressive 
and blindness results. When optic atrophy occurs early, ataxia may 
not appear; this is known as "tabes arrested by blindness." When it 
develops later it has no effect on the ataxia, (d) Deafness may develop 
gradually or suddenly, sometimes with vertigo or Meniere's complex. 
It may be permanent or transient. Auditory defects are present in 80 
per cent, of cases. Atrophy of the auditory and olfactory nerves has 
been found. 

5. The Sphincters and Genital Sphere. — (a) The bladder is frequently 
affected (45 to 80 per cent.), possibly as the first symptom of the disease. 
The bladder is slowly or imperfectly evacuated, because its centripetal 
sensory fibers are diseased. There may be overflow, incontinence, and 
in the later stages cystitis frequently results from decomposition of the 
residual urine, followed in turn by pyelitis, nephritis and septicemia. 
(b) The sphincter ani is somewhat weak; there is rarely incontinence. 
Constipation is the rule, (c) The sexual appetite and power are 
reduced (58 to 76 per cent.), often early. Labor is not interfered with 
and is sometimes painless. 

6. Trophic Disorders. — The general nutrition sometimes suffers, but 
local trophic changes are much more common, (a) Trophic alter- 
ations in the bones and joints, described by Cruveilhier and Mitchell, 
were first thoroughly studied by Charcot, after whom they are named, 
Charcot's disease. They usually appear late and develop in 2 per cent, 
of cases. The onset of articular changes is usually gradual, sometimes 
acute with marked swelling, or may seem to be traumatic. Two forms 
are observed; first and more frequently the atrophic form, especially 
in the hip and shoulder, in which the cartilages are eroded, the articular 
surfaces waste and crepitate, foreign bodies sometimes develop, and 
the joint becomes too lax, and dislocation of the hip or knee (genu 
recurvatum) results; second, the hypertrophic form with bony for- 
mation, ossification of the ligaments, and rigidity resembling arthritis 
deformans but more acute, extreme and effusive. The adjacent 
muscles atrophy — the arthropathic muscular atrophy. The large 
joints are usually involved, as the knee (45 per cent.), hip (20 per cent.), 
shoulder (11 per cent.), elbow (5 per cent.), or ankle (4 per cent.), but 
smaller articulations may be affected, as the tarsus (8 per cent.") or Less 
often the jaw, spine, thumb, etc. The tabetic joint is painless. The 



1120 DISEASES OF THE NERVOUS SYSTEM 

cause is the same as in syringomyelia; the anaesthetic joints are moved 
inappropriately and the nutritional reflex (which normally depends on 
centripetal influences) is lacking (Marinesco and Serieux). The tabetic 
foot is characterized by thickness and roundness of its inner border and 
arch, flattening of the sole, decreased motility and pathologically by 
erosion and atrophy of its bones. It must be distinguished from the 
tabetic club foot due to muscular atrophy of the calf muscles with con- 
tractures. The bones are friable and break easily but painlessly, as first 
described by Wier Mitchell. Fracture is due to rarefying osteitis, 
which renders the medullary substance more porous, the cortex thinner 
and the inorganic base less in amount. If a callus develops, it is often 
exuberant. The tendons sometimes rupture, probably from trophic 
changes, (b) The perforating ulcer of the foot imal perforant du pied) 
is more frequent. It is " punched out" in appearance, and thickening 
precedes ulceration; it is usually painless, secretes but little pus and is 
due to nerve degeneration. Similar ulcerations resembling syphilis 
may occur in the nose, ear, buccal mucosa, palate or uvula, (c) In the 
skin, local sweating, ecchymoses, herpes, blebs, alteration of the hair or 
nails, gangrene and ichthyosis may occur. Decubitus is not common 
save in the last stages, and it may not develop even after years in bed. 
There may be painless falling out of the sound teeth with analgesia of 
the gums or there may be dental caries, referred to changes in the 
fourth ventricle (Demange). 

7. Of the visceral symptoms, the most important are the painful 
crises described by Delmarre but first correctly interpreted by Charcot. 
(a) Gastric crises occur in 5 per cent, of the cases. There is severe 
sometimes excruciating epigastric pain, which often radiates into the 
back, vomiting (with or without nausea) of food, then fluid, finally 
bile or even some blood; this is often attended by restlessness, epi- 
gastric retraction, hiccough, fever and a slow or rapid and irregular 
pulse. A test meal gives varying results; hyperacidity is less frequent 
than hypacidity. The urine is alkaline, contains indican, and the 
chlorides are decreased. The crisis lasts several hours to several 
days (even 8 or 10) and may greatly reduce the general nutrition ; it 
recurs and is sometimes the first evidence of tabes. The cause of the 
crisis is hard to explain; it is usually considered nervous, but Pal thinks 
it is due to increased arterial tension, (b) Laryngeal crises are next 
in frequency but are shorter in duration. They are due to spasm of the 
laryngeal muscles, and are often dangerous. In some instances only 
a hoarse cough like that of pertussis is noted; in others there is collapse 
or death (ictus laryngis). Anatomically, the ascending branch of the 
fifth nerve and the glossopharyngovagus nucleus or its branches are 
degenerated, (c) Other crises are far less common, as intestinal crises, 
which are characterized by colic, diarrhoea and sometimes rectal 
tenesmus; the author saw one case with severe constipation lasting 
12 days, which was immediately relieved by morphine gr. \\ renal 
crises with scant urine, transient albuminuria or even hematuria, and 
less often nasal, pharyngeal, hepatic, cardiac, bronchial, vesical, 






TABES DORSALIS, LOCOMOTOR ATAXIA 1121 

urethral or vulvovaginal crisesoccur. (d) The pulse in tabes frequently 
reaches a rate of 100 or 120. Lachrymation, salivation, polyuria or 
glycosuria are sometimes noted. 

8. Cerebral symptoms, other than the eye changes noted above, are 
not frequent; they are unilateral atrophy of the tongue; paralysis of 
the vocal cords, especially of the abductors; vagus and accessorius 
symptoms other than those already noted, such as rapid pulse, palatal 
weakness or rarely paralysis affecting the trapezius and sternomastoid, 
which is probably neuritic; and very rarely facial or bulbar paralysis. 

Complications. — These include hysteria, neurasthenia, Graves' 
disease, paralysis agitans; true cerebrospinal syphilis; other meta- 
syphilitic maladies, as arteriosclerosis, aneurysm (10 to 20 per cent.), 
valvular disease, arteriosclerotic aortic regurgitation (2 to 9 per cent.) 
and especially dementia paralytica, which is maintained by some to be 
a cerebral tabes but more correctly held to be an independent although 
closely correlated affection; myelitis; general or local muscular 
atrophy, particularly the symmetrical form (Dejerine) due to neuritis; 
cerebral thrombosis due to concomitant arterial disease; and apoplec- 
tiform seizures which occur as in paretic dementia. 

Course and Prognosis. — The typical progress of the disease by stages 
(v. s.) may be altered. According to Sarbo, pain is the first symp- 
tom in 68 per cent, while no other single early symptom is the first in 
more than 3 per cent. The disease in rare cases begins acutely. Not 
over 50 percent, are progressive (Gowers). Optic atrophy or insanity 
may arrest tabes. In the early stages or in rudimentary forms, there is 
a slight chance that the symptoms may become stationary, but not after 
ataxia fully develops. Tabes is incurable. Leube mentions an instance 
of a man who worked hard for forty years after the onset of tabes; 
tabetics may live for twenty years in the last stages of the disease. 
Crises, especially the gastric crisis, alcoholism, traumatism, acute on- 
set, intercurrent affections which may be unnoticed because of their 
painlessness, typhoid, and affections of the bladder and kidney with 
sepsis are unfavorable prognostics. In 1,960 well-observed cases (out 
of 4,000) 40 per cent, followed a long course with exacerbations, 30 per 
cent, were steadily progressive, 19 per cent, halted for three years or 
more, 6 per cent, ran a severe rapid course, and 5 per cent, almost 
recovered (Belugou and Faure, 1903). 

Diagnosis. — The diagnosis is usually very easily made and is based 
on the following signs in various combinations: — (a) The Argyll- 
Robertson pupil, which according to Mobius is practically indicative 
of tabes, paretic dementia or rare lesions in the corp. quadrigemina. 
(b) The most common and early symptom, WestphaVs sign, loss of the 
patellar reflex (which most rarely fail in health, marasmus, old 
individuals or as an hereditary lesion), (c) Lightning pains, "tabetic 
neuralgia," girdle sensation, gastric and other crises, (d) Sensory 
changes, subjective and objective, including bladder disturbance, (e) 
Optic atrophy. (/) Painless ocular paralysis, particularly in the adult 
and of the nuclear form, producing ptosis, and diplopia, (g) Ataxia, 



1122 



DISEASES OF THE NERVOUS SYSTEM 



which usually does not develop early, with Romberg's sign and the 
tabetic gait, is practically pathognomonic after exclusion of peripheral 
neuritis. 

In less than 1 per cent, of cases (Dejerine) the disease is located 
in the cervical region ; and in this cervical tabes, the sensory changes, 
pains, and ataxia are most manifest in the arms, or even in the face. 
The arm reflexes are sometimes abolished, and the patellars may 
rarely be normal or increased. The characteristic pupils are almost 
always present, and gastric crises appear early and very frequently. 
The diagnosis of atypical tabes may long remain uncertain, as in cases 
in which ataxia, WestphaFs sign, and the Argyll-Robertson pupil are 
absent, or in those with unusual symptoms, as marked motor weakness, 
atrophy, or paralysis. 

Differentiation. — In the earliest stage, confusion with neurasthenia, 
hypochondriasis and nosophobia is possible, from common symptoms, 
as pains, paresthesia, girdle sensation, and weakness of the legs, but 
close continued observation usually determines the diagnosis; the tabes 
of Hippocrates was probably neurasthenia. One of the forms of peri- 
pheral (multiple) neuritis, (q. v.), viz. acute ataxia, or pseudotabes, may 
require differ entiation. Cerebrospinal syphilis, especially of the roots 
and the membranes, may sometimes cause confusion. 



Tabes 

Gradual onset; very slow progress. 

Blindness often complete; marked 
ophthalmoscopic changes. Hemian- 
opsia not common; rarely central 
scotoma. Argyll-Robertson pupil. 



Symptoms bilateral. 

Oculomotor nerve symptoms may cause 
the greatest difficulty, since the 
closest relation (Erb) exists between 
the two diseases as regards this nerve, 
yet painless in tabes and nuclear in 
origin. 

Crises and anaesthesia of the fifth nerve, 
laryngeal paralysis. 



Sensory nerves most involved. 

Paralysis very rare. 

Knee jerk absent. 

Ataxia. 

In syphilis and parasyphilitic diseases 
(tabes), lumbar puncture shows pre- 
dominance of mononuclear cells. 



-Syphilis. 



More rapid. 

Blindness rarely total; ophthalmo- 
scopic changes may be few or none, 
yet with great disturbance of func- 
tion. Amaurosis, etc., acute or sub- 
acute, "in installments" ; central 
scotoma with free periphery. No 
Argyll-Robertson pupil. 

Often unilateral. 

Oculomotor symptoms with headache 
(meningitis and nerve trunk involve- 
ment). 



Crises, anaesthesia of the fifth nerve, etc., 
rare. Anaesthesia of the fifth is for 
all varieties of sensation, while tabetic 
anaesthesia is for pain. 

Motor nerves mostly. 

Paralysis frequent at some period. 

Knee jerk variable, increased. 

Rare. 

Remissions frequent with greater vari- 
ability and brusqueness than in 
tabes. 



TABES DORSALIS, LOCOMOTOR ATAXIA 1123 

Tabes and paretic dementia have a common etiology but in the latter 
the pyschical alteration is characteristic. For differentiation from 
Friedreich's ataxia, see page 1135. In cerebellar tumor, the ataxia 
usually ceases when the eyes are closed, and is not characterized by the 
excessive excursion or rapidity of tabes; in most cases the patellar 
reflexes are increased, there is no anaesthesia, and signs of tumor are 
often present. In multiple sclerosis there may in exceptional cases be 
crises, pains, and sensory disturbance, but the Argyll-Robertson pupil, 
ataxia, marked sensory and bladder disturbances are most rare. The 
reflexes are increased, there is nystagmus, scanning speech, intention 
tremor and central scotoma, and functional oculomotor involvement 
is more frequent. Paraplegias are not difficult to differentiate, since 
true motor disturbance is rare and of late occurrence in tabes; the 
reflexes are increased and spastic rigidity is marked, even in atactic 
paraplegia. Tabetic pain is often misinterpreted; pain as a rule 
suggests disease of the vertebrse and membranes rather than of the 
cord itself, but in vertebral disease or cord tumor the pain is fixed, 
and is often increased on pressure and movement. Tabes may be 
confused (but only on hasty or partial examinations) with rheumatism, 
intercostal or trigeminal neuralgia, and gastric, renal or other visceral 
disease. Bilateral sciatica always suggests tabes, diabetes, or nephritis. 
Strumpell describes, among workers in tobacco, a nicotine tabes, in 
which pain, pupillary alteration, atactic gait and absence of knee jerks 
are observed, but which presents a characteristic tremor and increased 
cutaneous reflexes in the legs. 

Treatment. — Since the disease is incurable, no therapy is especially 
efficacious. 

1. Etiological Treatment. — Antisyphilitic remedies are at first 
indicated, but their frequent and almost regular failure has led some 
writers to erroneously deny the causal connection between syphilis and 
tabes. Tabes is not active syphilis; it is a late degenerative para- 
syphilitic affection. Mercury and iodides are therefore advantageous 
chiefly either in early cases or in those in which gummatous changes 
co-exist with tabes. They apparently arrest some cases of optic atrophy. 
Mercury is thought by Erb to be beneficial if it is used carefully; it 
may be administered, but should be discontinued at once if untoward 
symptoms develop. 

2. Hygienic Treatment. — Overwork, overexercise, worry, fatigue, 
trauma, exposure, and excess in tobacco, alcohol or in sexual indulgence 
should be avoided. Tabetics should not marry. The diet should be 
regulated, since dyspepsia promotes pain. If possible, the patient 
should live in a warm climate and at a moderate altitude. 

3. Drug Treatment. — There is no specific remedy. Silver, strych- 
nia, and nitroglycerine give uncertain results. Gowers considers 
arsenic beneficial. 

4. Balneotherapy. — Warm baths are injurious; lukewarm baths 
are best, but exert no specific influence on the disease. The same is 
true of (5) electrotherapy, and (6) massage. 



1124 DISEASES OF THE NERVOUS SYSTEM 

7. Symptomatic Therapy. — (a) If pain is superficial, sinapisms, 
chloroform liniments, cocaine (hypodermaticaHy) or the galvano- 
cautery should be tried; if moderate, acetanilide or cannabis indica, 
are beneficial, but morphia should be avoided as long as possible, 
because the habit is readily acquired. Peripheral faradization is often 
efficacious. Gowers recently described cases in which pain was a 
salient symptom and existed without ataxia or loss of the patellar 
reflexes: for this "tabetic neuralgia/' differing from the ordinary pains 
of tabes, he recommends salicylates and aluminium chloride, gr. v-x 
t. i. d. (b) Crises resist milder therapy and usually necessitate the use 
of hypodermics. Laryngeal crises often respond to nitroglycerine 
hypodermaticaHy, chloroform by inhalation or cocaine locally. Stretch- 
ing the [spine and cord probably relieves pain; the patient sits on the 
floor with the legs extended; without other movement, the body is 
carefully pushed forward as far as possible, (c) For vesical affections, 
catheterization for residual urine is indicated, but under most rigid 
antisepsis; belladonna and faradization are often beneficial. Cystitis 
is treated by lavage, id) Secondary infection should be avoided. 
Corns should never be cut but always rubbed off. 

8. Ataxia. — This may be relieved by H. G. Franker s systematic 
exercises, "a reeducation of the central nervous system by repeated 
exercises/' which teaches that carefully and persistently executed 
muscular movements, not forceful movements, are desirable. (The 
nerve stretching of Langenbuch and the suspension method of Mitchell 
are useless and even injurious). 



II. System Diseases of the Motor Tract. 

The centrifugal or motor paths may be diseased (1) in the upper 
neurone, as in spastic spinal paralysis; (2) in their entirety; this 
affects both neurones, as amyotrophic lateral sclerosis; (3) in the 
peripheral neurone, as spinal muscular atrophy or its cerebral analogue, 
progressive bulbar paralysis; (4) in the peripheral motor nerves, as the 
neuritic muscular atrophy and finally (5) in the muscles themselves, 
as the muscular dystrophies. These forms are probably more or less 
correlated and some of the types blend, but separate descriptions are 
necessary in order to bring out clearly the classical symptoms and 
physiology (though the classification of cases into those with and 
without disease of the spinal gray matter, is more simple). 



1. Spastic Spinal Paraplegia. 

Lateral sclerosis, tabes dorsal spasmodique, was described first by Erb 
in 1875, and later by Turck and Charcot. Though amyotrophic lateral 
sclerosis affects both neurones and the muscular atrophies the lower 
neurone in the cord, nerves or muscles, this malady concerns only 



SPASTIC SPINAL PARAPLEGIA 1125 

the upper motor neurone, especially that part which is in the cord, 
although it has been traced at times to the cortex. 

Etiology and Pathology. — The disease represents a clinical symptom 
complex rather than a pathological entity. The causal factors are 
uncertain, as syphilis, or occasionally an hereditary tendency. In 75 
per cent, of cases it occurs between the twentieth and fortieth years. 
It was thought that there was a primary sclerosis of the lateral pyra- 
midal tracts, especially in their lower parts, for which unequivocal 
confirmation is still lacking, for the cases of Erb, Charcot, Strumpell, 
Dreschfeld, and Minkowski were not wholly confined to these tracts 
and there were some changes in other neurones, as in the post, columns. 

Symptoms. — There are three cardinal findings, (a) Motor weak- 
ness, which is usually paraplegic; (b) muscular rigidity, and (c) 
increased reflexes, (a) Motor weakness is usually the first sign; it 
begins slowly and is evidenced by weakness, fatigue or stiffness in the 
flexors of the hips especially but also of the knees and ankles. Every 
gradation from paresis to paralysis may be noted in different cases or 
in different stages. The arms rarely are first affected. Unilateral 
paresis, as of one arm and one leg, is very exceptional. Strumpell 
attributes the loss of finer synergistic movements to involvement of the 
lateral pyramidal tracts; he holds that the coarser movements for 
groups of muscles are possible, via the anterior pyramidal tracts. The 
muscles are large and well nourished. (b) Muscular rigidity (hyper- 
tonicity) results also from disease of the lat. pyram. tracts, which lessens 
the inhibition and is proportionate to the loss of power. The muscles 
resist passive efforts at flexion, especially quick efforts, but yield to slow, 
gradual flexion and remain in the position given them; this is the " lead 
pipe contraction^ of Wier Mitchell. The knees are rigidly extended, 
even when the patient sits on the edge of the bed; the great toe is 
strongly flexed dorsally; when one leg is lifted as he lies in bed, the 
other comes with it; the specially tense adductors prevent abduction 
of the thighs. The muscles are stiff in the morning; painful spasms 
may occur during the night; hypertonicity may lead to contractures 
which are largely active in character and patients sometimes complain 
of the "tendons getting too short. " In active movements rigidity is 
manifest; the gait is paretic and spastic, the knees are extended 
and closely apposed, the steps are short, the balls of the feet seem 
to cleave to the ground, and the feet scuffle, (c) Increase of the 
reflexes is also due to lateral pyramidal sclerosis. The knee jerks are 
most excessive; ankle clonus and Babinsky's reflex are present; a 
strong clonic contraction of the quadriceps follows depression of the 
patella, and the gait may be hopping; in short, this is the so-called 
"spinal epilepsy," (Brown-Sequard). The arms are often normal but 
may show weakness; there may be rigidity like that of a late hemi- 
plegia, although less in degree, in which the arms hug the chest, the 
forearm is pronated and partly flexed and the fingers are flexed ; there 
may be clonic spasm of the fingers, and increased tendon and 
periosteal reflexes. In the trunk, there sometimes is weakness in the 



1126 DISEASES OF THE XERVOUS SYSTEM 

back and painful contractions of the chest and back muscles with dull 
aching. The cranial nerves are rarely diseased, although the jaw-jerk 
may be increased. Sensation, the electrical reactions, the sphincters, 
muscular nutrition, and the eyes are usually quite normal. If there are 
sensory symptoms they are rarely objective; the sphincters are usually 
affected late. 

Clinical Forms and Diagnosis. — Diagnosis concerns (a) the paresis, 
(6) hypertonicity, (c) increase in the reflexes, id) gradual onset, and (e) 
absence of sensory, trophic and other symptoms. Six clinical forms 
may be described. (1) There is rigidity and spasticity in the legs, arms 
and perhaps the face, sometimes with compulsory laughing or weeping, 
as in amyotrophic lateral sclerosis, but without muscular atrophy. 

2. The hereditary or familial form (Erb, Bernhardt, Strumpell, 
Spiller) commences in persons between twenty and thirty years of age ; 
the paresis develops late; this form is characterized anatomically by 
sclerosis of the (congenitally weak) lateral pyramidal tracts, and also by 
sclerosis of the cerebellar and Goll's columns (this would be more 
properly classified under combined system disease). 

3. In infantile forms (see Cerebral Paralysis in Children), the 
rigidity is less; foot-clonus less common; tonic spasms are rare; athetoid 
movements,deficient mentality and epileptiform convulsions are common. 

4. In the syphilitic form of Erb, there is paresis and slight spasti- 
city, plus urinary incontinence, retention, and impotence. 

5. There are forms which are symptomatic of brain disease (tumor, 
syphilis, paretic dementia, encephalitis, hydrocephalus), cord disease 
(tumor, myelitis, compression, syringomyelia, multiple sclerosis), and 
hysteria (which may closely simulate spastic paraplegia) ; hysteria has 
not the peculiar extensor spasm, loss of power is rarely complete, and 
ankle clonus is rare, although a spurious half voluntary contraction 
of the calf muscles may be noted. 

6. Westphal, Charcot, Schachnowitch, but especially Goldflam, 
have described periodic familial paralysis, which affects the legs and 
less often the arms, is flaccid, and results in decrease of the patellar 
and absence of the plantar reflexes, decreased faradic irritability, 
sleepiness, but without sensory symptoms; it lasts one to three days. 
The prognosis is good. 

Prognosis. — The disease may be stationary for years and its course is 
chronic. "It is perhaps the least dangerous to life of any chronic 
spinal lesion/' Recovery or arrest is rare. 

Treatment. — Much exercise, fatigue, electrotherapy and strychnia 
are to be avoided. Massage and warm baths relieve the spasticity .. 
Otherwise the therapy is expectant. 



2. Amyotrophic Lateral Sclerosis. 

This was often called the Maladie de Charcot, because Charcot. 
(1865) with Joffroy first described it. 



AMYOTROPHIC LATERAL SCLEROSIS 1127 

Etiology. — It occurs mostly between the twenty-fifth and forty-fifth 
vears, more frequently in males, but its exact causes are not known, 
although cold, trauma, and overexertion are possible factors. 

Pathology. — Changes may be found from the cerebral cortex to the 
muscles themselves, but the name amyotrophic lateral sclerosis, left 
to us by Charcot, designates the leading changes, which are, amyotro- 
phy, muscular wasting, from atrophy of the anterior horns and sclerosis 
of the lateral columns, (a) The lateral pyramidal tracts, and to a lesser 
extent the anterior, show symmetrical primary degeneration of the 
nerve fibers, followed by interstitial overgrowth (secondary sclerosis) 
which is most marked in the cord, i. e., the lower part of the upper 
neurone, but extends upward (Charcot, Marie) in some cases to the 
medulla, pons, crus or even to the very central convolutions, the 
ganglionic cells of which may be atrophied. Charcot's belief that the 
disease starts in the pyramidal tracts and is followed by changes in the 
anterior horns (v. i.) is not proven. In some cases similar but un- 
important changes may be found in the cerebellar tracts or indeed in the 
posterior columns, (b) The ganglionic cells of the anterior horn are 
degenerated, so that the anterior motor part of the cord is distinctly 
smaller and flatter, particularly in the cervical region. Likewise the 
nerve fibers from the pyramidal fibers, anastomosing with the pro- 
cesses of the ant. horn, are degenerated. With these changes in the 
trophic centre of the second motor neurone, the atrophic changes in the 
anterior roots, motor nerves and muscles, are easily explained. Certain 
muscles are wasted to a varying degree, and show degeneration or 
complete atrophy, as in the purely spinal progressive muscular atrophy, 
next to be described, (c) The bulbar nuclei, with their nerves and mus- 
cles, show identical changes, for they are the analogues of the ant. 
horns. 

Symptoms. — The symptoms, like the lesions, are strictly motor. 

Stage 1 of Charcot. — The disease begins with weakness and 
atrophy of the muscles of the hand, first in one and then in the other; 
they are most marked in the thenar, hypothenar and interosseal 
muscles, and are followed by wasting and weakness in the forearm 
extensors, deltoid and triceps, while other muscles of the arm and 
forearm escape or are involved later. There may be some tingling in 
the parts affected, but sensory symptoms are absent. The decreased 
power of unwasted muscles is often manifest before they atrophy. 
Other symptoms of disease of the lower neurone appear, as fibrillary 
contractions; the reaction of degeneration is present in those muscles 
which are wholly atrophied, while in others the response is reduced 
proportionately to the atrophy; the nerve trunks respond normally. 
Evidences of involvement of the upper neurone also appear; paralysis 
often precedes the wasting and accentuates the weakness from ant. 
horn involvement; there is increase of the reflexes (which never occurs 
in muscular atrophy due to disease of the ant. horns alone), increased 
biceps, triceps, and periosteal forearm reflexes, and there is often rigidity 
and contracture in which the arm hugs the chest, the forearm is flexed 



1128 DISEASES OF THE NERVOUS SYSTEM 

and pronated, and the wrist and fingers are flexed. Sometimes the 
neck is rigid and even trismus is observed. 

• Stage 2. — In less than a year the legs are involved; indeed they show 
symptoms during the first stage. The legs are weak, especially in the 
flexors of the hip, knee and dorsal flexors of the foot. Spastic symptoms 
prevail. The legs resist passive movement, because of increased 
muscle tonus and the increased reflexes. The gait is spastic and paretic 
(see above, Spastic Spinal Paralysis) and walking finally becomes 
impossible because of the rigidity and the twitching tetanic movements 
of the extensors. The patellar reflexes are exaggerated; ankle clonus is 
frequent ; when the patient attempts to flex the thigh while the exam- 
iner holds the ankle, there is a visible contraction of the tibialis amicus 
(the tibialis phenomenon); Babinsky's reflex is present (dorsal instead 
of plantar flexion on stroking the sole) ; there are evidences, in short, 
of pyramidal disease, which dominate the leg symptoms, because 
symptoms referable to the lower neurone, as atrophy, are much less 
frequent, less marked and less early in the legs than in the arms. In 
exceptional cases the leg symptoms develop first. 

Stage 3. — This stage occurs in one or two years with bulbar symp- 
toms, dysphagia, atrophy of the. lips and tongue with fibrillation, as in 
primary bulbar paralysis (q. v.). On tapping the jaw, a marked jerk 
is elicited, analogous to the increased reflexes in the arm and leg. A 
tonic tension of the facial muscles may occur as in spastic spinal 
paralysis. Spasmodic laughing or weeping almost always occurs and is 
due to loss of inhibitory innervation. The mind is clear. Death results 
from respiratory failure, aspiration pneumonia or intercurrent disease. 
In rare cases the bulbar symptoms antedate atrophy in the arms and 
spasticity in the legs. 

Course and Prognosis. — In some cases the spinal, in others the 
atrophic, symptoms develop first and are dominant. The entire course 
is rapid compared with other diseases of the group , covers one to four 
years, and is always fatal. 

Diagnosis. — The involvement of both motor segments, muscle 
atrophy with increased reflexes, rigidity, absence usually of sphincter or 
sensory alteration (except rarely some pains) and the final bulbar 
symptoms make the disease easy of diagnosis. 

The treatment is that of spinal muscular atrophy (v. i.), but avails 
little. 



3. Progressive Spinal Muscular Atrophy. 

Duchenne and Aran (1849-50) gave us the first full clinical descrip- 
tion of this disease, while Clarke, Luys, (1860) and then Charcot, 
discovered changes in the anterior horns. 

Etiology. — The ultimate causes are not known. Seventy-five per 
cent, of cases occur in males, mostly between the twenty-fifth and 
forty-fifth years. Hereditary factors, which are often observed in the 



PROGRESSIVE SPIXAL MUSCULAR ATROPHY 1129 

muscular dystrophies (v. L) are infrequent, although Werding (1891), 
Hoffman (1894), Bruce, Osier and Thompson have described familial 
infantile forms. Hard work, mental distress, syphilis, trauma, acute 
infections and acute poliomyelitis are possible factors. 

Pathology. — In the cord, especially in the cervical region, (a) the 
ant. horns are small and flattened; their ganglion cells are shrunken, 
deformed, their processes lost; they are wholly wasted in advanced 
cases. Any interstitial changes are wholly secondary. (b) The 
anterior roots, especially the cervical, are somewhat degenerated, and 
often also the peripheral nerves, although changes in them are most 
difficult to distinguish, (c) The muscles are small, stringy and pale, 
having lost their normal redness. Microscopically their individual 
fibers are small, although a few normal or even hypertrophic fibers may 
be seen. Their transverse striation persists remarkably, and waxy, 
fatty or granular degeneration and longitudinal splitting are not 
common; sometimes the empty sheaths alone are seen. The muscle 
nuclei multiply, round cells may wander in, and there is usually increase 
of connective tissue and sometimes fatty deposit. Just where the process 
begins is disputed. No close distinction can be drawn between this 
disease and amyotrophic lateral sclerosis, although changes in the 
upper neurone are absent in spinal muscular atrophy. Gowers and 
v. Ley den consider them identical; Kahler and Pick held that both 
these diseases and bulbar paralysis are one affection. 

Symptoms. — (a) The essential symptoms are those of the motor 
nerves, and all others are accessory. The earliest symptom is muscular 
atrophy with weakness in the upper extremity (90 per cent.), especially 
in the muscles of the (right) thenar and hypothenar eminences. The 
abductor and opponens pollicis are first involved, then the flexor brevis 
and adductor, the wasting of which brings closer together the meta- 
carpi of the thumb and index finger (the "ape hand"). It is finally 
impossible to appose the thumb to the fingers. The interossei on the 
dorsum waste and leave marked furrows, producing the "claw hand," 
main en griffe, from contraction of antagonist muscles, the ext. 
digitorum communis, the tendons of which stand out prominently. 
The wasting lumbricales make the palm more hollow. Wasting as 
above described is known as the Duchenne-Aran type, in which 
"individual muscles" are selectively involved (Charcot). The onset 
and progress are always very gradual, and the muscles become lax, 
soft, thin and flat. The atrophy long exceeds the paresis. The forearm 
may be next involved, first the extensors, especially those below the int. 
condyle and later the supinators and flexors. A deep depression 
between the ulna and radius eventually occurs. Later, often after 
several years, the shoulder muscles, the posterior and middle third of 
the deltoid, the biceps and brachialis waste, and much later the triceps. 
Sometimes the wasting of the muscles of the shoulder and arm immedi- 
ately follows the involvement of the hand, or perhaps the disease 
begins in the shoulder. The bones of the shoulder stand out clearly, 
covered only by the skin; these cases are "the living skeletons" 



1130 DISEASES OF THE NERVOUS SYSTEM 

seen in museums. The trunk muscles are involved in this order; 
trapezius in its middle and lower parts (rarely in its upper third, which 
is the ultimum moriens of Duchenne); pectoralis, latissimus dorsi, 
rhomboidei (causing the shoulder to droop) and extensors of the head, 
(allowing the head to fall forward). Scoliosis may develop, lordosis is 
common in involvement of the extensors of the trunk and hip, and the 
spine stands out distinctly in cases of extreme atrophy. The platysma 
and face almost always escape. In most instances the respiratory 
muscles, intercostals or even the diaphragm are involved, and this 
is a not infrequent source of danger to life. The abdominal muscles are 
sometimes weakened. In the leg the muscles are affected late and to a 
lesser degree, as the glutei, quadriceps, and the peronei. In very 
exceptional cases the disease first develops in them. In the fully 
developed case there is extreme helplessness in which an added misery 
in the form of the sister-process, bulbar paralysis, may develop. 

(b) In the wasted and weak muscles there are usually fibrillary con- 
tractions; they are involuntary twitchings, tremor- or even wave-like in 
character, which are sometimes incessant, and again are initiated only 
by cold, or tapping; they show increased mechanical irritability. They 
may appear in muscles not yet wasted and are not to be confused with 
the similar neurasthenic fibrillation, (c) The electrical reaction depends 
on the degree of wasting. In the nerves it is normal. In the muscles 
there is usually only quantitative reduction, and the voltaic excitability 
remains long after the faradic is lost; in the last stages there is a 
partial reaction of degeneration, (d) The reflexes are weakened or 
abolished; they are roughly proportionate to the atrophy and due to 
disease in the motor side of the reflex arc. They are never increased. 
The sphincters are intact, but sexual power is often lost, (e) Sensation 
shows no objective change, and even subjective paresthesia is rare; 
in some instances there are dull aching pains in the muscles or joints. 
(/) Vasomotor, secretory and trophic symptoms are lacking. The 
coolness of wasted parts is due to lack of motility. 

Diagnosis. — The diagnosis is based on (a) the slow course; (b) the 
involvement of the muscles of the hand and its slow "individualiza- 
tion"; (c) fibrillation; (d) partial reduction in electrical irritability 
or partial reaction of degeneration; (e) absence of increased reflexes 
and (/) of any sensory signs. 

Differentiation is necessary (1) from disease in which muscular 
atrophy is but one among several symptoms, (a) Syringomyelia is 
marked by its trophic characteristics, its analgesia, thermo-anses- 
thesia and less symmetrical wasting. (6) Meningitis, pachymeningitis, 
spondylitis, tumors and myelitis, are manifested by anaesthesia, pain, 
tenderness, and rigidity, (c) In root neuritis or multiple neuritis there is 
a clearer reaction of degeneration, more sensory signs and more 
tenderness in the nerve trunks, (d) The atrophies caused by an indi- 
vidual 's occupation are distinguished by the history and slight sensory 
disturbance. 



XEURITIC MUSCULAR ATROPHY 1131 

(2). Other muscular atrophies must be differentiated, (a) Subacute 
and chronic poliomyelitis causes paralysis first and atrophy afterward ; 
it affects groups of muscles at once, its course is not gradual but rapid 
and fibrillary contractions are infrequent, (b) The myopathic atrophies- 
must be distinguished (see p. 1135). (c) Amyotrophic lateral sclerosis is 
an allied, perhaps an identical affection; Charcot held that the atrophy 
is not "individualized," but occurs en masse-, the distinguishing 
features are the increase of the reflexes, spasticity, and a much more 
rapid course. Gowers has never seen a case of progressive spinal 
atrophy without anatomical change in the pryamidal tracts; in describ- 
ing the two affections together, he distinguishes three varieties (i) 
extreme atonic atrophy, (ii) muscular spasm and weakness with little 
or no atrophy, and (iii) moderate tonic atrophy with increased myotatic 
irritability, (d) Arthritic muscular atrophy, probably due to reflex 
influences, or direct extension of inflammation to the muscles or nerves, 
may be acute or chronic, and involves chiefly the extensors in a moder 7 
ate wasting; diffuse wasting suggests a nervous cause; the history or 
evidence of joint disease is distinctive. The electrical reactions are 
normal or show only slightly decreased excitability. There is usually 
distinct increase in myotatic irritability and reflex action. 

Course and Prognosis. — The onset between the twenty-fifth and 
forty-fifth years is gradual, the course is slowly progressive, remissions 
infrequent, arrest very rare, and death usually results from intercurrent 
disease, respiratory affections (tuberculosis) or bulbar palsy. Gowers 
observed arrest but rarely, and then chiefly in cases marked by sym- 
metry and synchronous involvement of both hands; arrest occurs, 
unhappily, chiefly late in the disease. 

Treatment. — Drugs are of uncertain value. Gowers gives strychnia 
hypodermatically; he has seen 7 consecutive Gases of arrest of which 
6 were permanent; it has little effect by mouth. Arsenic and iodides 
are employed. Massage, active and passive gymnastics and electricity 
are always indicated but do not stay the disease. 



4. Neuritic Muscular Atrophy. 

Charcot-Marie type. Peroneal family type (Tooth). Neuritic type 
(Hoffmann). 

Etiology. — It is often hereditary, even through five generations; it 
is usually familial. It occurs in the second half of childhood, and 
rarely after the twentieth year. Sixty-six per cent, of cases are in males. 

Pathology and Symptoms. — The pathological characteristic is 
neuritis, which Hoffmann thought might ascend to the post, roots; 
secondary changes have been seen in Goll's column. Early atrophy 
occurs in the small muscles of the feet and may not attract attention until 
bilateral symmetrical peroneal paralysis and atrophy develop, together 
with paralysis in the long toe extensors, and club feet (pes equinus 
or varo-equinus). The calf muscles are the next to suffer and the thigh 



1132 DISEASES OF THE XERYOUS SYSTEM 

is involved still later. Then after years, paralysis and atrophy of the 
hands, as in progressive spinal atrophy, develop, with the "claw hand"; 
in involvement of the forearm, the extensors suffer more than the 
flexors. The shoulder, neck, trunk and face are seldom diseased. 
Fibrillation is infrequent; the reaction of degeneration is generally 
present, sensory manifestations are common as pains or anaesthesia 
(especially plantar), and reflex action is decreased or abolished, though 
the patellar reflexes may long persist. 

The diagnosis is based on the hereditary or family history, the age, 
localization and signs of slow neuritis. Treatment, as in other forms of 
muscular atrophy, is unsuccessful. 



5. Muscular Dystrophy. 

The progressive muscular dystrophies (Erb) or myopathies (Charcot) 
are often classed with diseases of the muscles, which indeed show the 
sole constant pathological lesions. They are so closely related clinically 
to the less frequent spinal atrophies that they are here considered. 
Their status is provisional, since changes in the cord, nerve trunks and 
nerve filaments have been found in some cases of each type. In all 
types (y. i.), with few exceptions, there are certain common character- 
istics; (a) heredity is an obvious cause in 56 per cent, of cases; though 
this factor may be absent, a familial incidence is often observed; the 
muscular system seems deficient in nutrition, development or vitality. 
(6) It usually occurs in childhood or pubescence, rarely in adult life. 
(c) The pathology is practically the same in all types; the muscles 
waste, with or without hypertrophy, or with increase of fat or interstitial 
growth, id) Being strictly a muscular affection, fibrillation and the 
reaction of degeneration are very rare, (e) In localization, certain mus- 
cles are involved, as those of the face (orbicularis oculi et oris), shoulder 
(pectoralis, latiss. dorsi, serrat. magnus, rhomboidei, trapezius), arm 
(biceps, brachialis, supin. long., triceps), trunk (erector spinse), glutei 
and thigh. Others are usually exempt, as the deltoid, supra- and infra- 
spinatus, small muscles of the hands and feet, leg muscles (gastro- 
cnemius), and those of the tongue and pharynx. There are three forms. 

Pseudohypertrophic Muscular Paralysis. — Lipomatous muscular 
atrophy is the least frequent, but is the longest and best known 
type. (Bell 1830, Partridge 1837, Meryon 1852, Duchenne 1861.) It 
occurs in males (80 per cent.), and is less marked, less early in life, and 
less fatal in women. It is often transmitted by healthy mothers, the 
males being impotent, and may be seen in five generations. It begins 
early (75 per cent, under ten years), and but rarely after twenty years 
of age. 

1. Impaired motility is the earliest symptom. The weakest muscles 
are the invisible hip flexors. Weakness of the hip and knee extensors 
makes climbing of stairs difficult, causes the waddling gait (paresis of 
glutei) and interferes with rising from the floor, so that the child must 



MUSCULAR DYSTROPHY 



1133 



Fig. 76. 



rise by resting on all fours, and then by "climbing his own legs with his 
hands " (Gowers). Paresis of the back muscles and hip extensors causes 
lumbar lordosis and abdominal protrusion. The ankle extensors also 
weaken. The child stands with legs far 
apart. The depressors of the shoulders 
are weakened early in the disease, later 
the shoulder muscles, then the biceps and 
triceps, but the hand remains normal 
for a long time, or is permanently un- 
affected. The weak muscles show nuclear 
increase, atrophy and division of their 
fibers, which are usually undersized, ir- 
regular in width, pale and narrow; fatty 
degeneration and loss of striation are 
rare. Increase of connective tissue is a 
later but most characteristic change. 

2. Certain muscles show apparent in- 
crease in size (pseudohypertrophy) , which 
is due largely to early adipose deposit or 
rarely to actual muscular hypertrophy. 
The muscles are lax. The calf muscles 
are especially enlarged, then the glutei, 
knee extensors, or infraspinatus which 
contrasts strongly with the wasted latis- 
simus and deltoid; the muscles of the 
face, neck and forearm seldom show en- 
largement. 

3. As to other symptoms, the electrical 
irritability is lowered, but there is no 
reaction of degeneration. The deep re- 
flexes decrease and disappear, from the 
muscular lesion. Mentality, sensation 
and the sphincters are normal. Con- 
tractures, such as the pes equinus, may 
occur late in the course. Cardiac hyper- 
trophy was observed by Glotz in 60 per 
cent, of his cases. The course is pro- 
gressive, the patient becomes bed-ridden, 
arrest is rare, and death occurs after 
years from intercurrent disease or from 
respiratory inflammation. 

Infantile Atrophic Form, with or with- 
out Facial Involvement.— There is usually 
no hypertrophy, but wasting occurs from the beginning. It may be 
combined with the first form, and the legs then show pseudo- 
hypertrophy and the arms simple atrophy. The pathology is that of 
pseudohypertrophic muscular paralysis, save that there is no hyper- 
trophy, true or false; increased connective tissue characterizes this 




Typical pseudohypertrophic muscular 
paralysis. (Dercum.) 



1134 DISEASES OF THE NERVOUS SYSTEM 

type of atrophy and also that of the juvenile form (see below). 

The face may be involved, as was first observed by Duchenne and 
later emphasized by Landouzy and Dejerine. The lids droop and 
cannot be wholly closed, the forehead is smooth, the cheeks are flaccid 
and droop, the lips part and functionate poorly, as in whistling, the 
lower lip protrudes, the nasolabial fold disappears, the face becomes 
expressionless, (the "fades myopathica"). Sometimes the buccinator 
muscles are implicated but rarely the masseters or those of the tongue, 
palate, larynx, pharynx, or eyeball. Simultaneously or more often 
later, the shoulder girdle wastes as in the first type; this is the facio- 
scapulohumeral form of Landouzy and Dejerine; the latissimus and 
lower part of the pectoralis are usually first affected, but in the biceps, 
triceps and often in the supinator longus, wasting and paresis are more 
conspicuous; the wasting is usually symmetrical. The forearm save 
for the supinator longus and the hand usually escapes. The neck is 
seemingly lengthened (Brissaud), because of the drooping of the 
shoulders and clavicles. The leg muscles then waste, especially the hip 
flexors, knee extensors and less often the glutei; lordosis, the waddling 
gait and symptoms observed in the next type (v. i.) may develop. The 
order given may be altered, for facial wasting may follow that of the 
arms. The course is usually progressive, very chronic (ten to fifty 
years) and the disease in itself rarely causes death, which results from 
intercurrent infections or respiratory catarrhs, tuberculosis, etc. In 
the second and third types, the prognosis is more favorable than in the 
first form and the outlook is better when the face is unaffected. 

The Juvenile Form of Erb. — This type begins after puberty, possibly 
later (twentieth to fortieth year), and is more frequent in women than 
the above forms. It begins more often in the shoulders and arms, than 
in the legs. The pectorals, latissimus, trapezius, serratus mag., rhomboi- 
dei, sacrolumbalis, longiss. dorsi, supinator longus and later the triceps 
are wasted, while the sternomastoid, supra- and infraspinatus, lev. 
anguli scapulae, coracobrachialis, teretes, deltoid, and the hand and 
forearm (except the supin. long.) are almost always exempt. If we 
lift the patient with our hands beneath his shoulders, he tends to "slip 
through"; this is due to "loose shoulders" (Erb). The scapulae stand 
out prominently from weakness of the serrati. In the lower limbs, the 
glutei, quadriceps and less often tibialis ant. and peronei become 
atrophied. The lordosis and gait are as above described. 

Diagnosis of Myopathic Atrophies. — (a) Atrophy from cerebral 
lesions is less marked than myopathic atrophy and more often follows 
the marked loss of power, (b) Spinal muscular atrophy (according to 
Leube) is differentiated as on page 1135. 

(c) Congenital spastic paraplegia occurs in children with weak legs 
and contractures in the calves but the history, increased reflexes, and a 
regressive rather than a progressive tendency easily distinguish it. 
(d) As to peripheral neuritis, the hereditary neurotic (neuritic) muscular 
atrophy (q. v.) is easily recognized. Multiple neuritis (q. v.) is usually 
toxic, more acute and shows sensory symptoms and local tenderness 



COMBINED SYSTEM DISEASES 1135 

Spinal Progressive Myopathic Progressive 

Muscular Atrophy. ' Muscular Dystrophy. 

Begins in small hand muscles. In trunk, shoulder, or pelvic girdle, leg 

and upper arm. 

Extends upward (face free). Progresses downward; face sometimes 

affected. 

Muscular atrophy. Frequently with hypertrophy. 

Fibrillation the rule. Very exceptional. 

Tendon reflexes may be increased in the Never increased. 

legs, if we include the amyotrophic 

lat. sclerosis. 
Reaction of degeneration, partial, Practically never present. 

perhaps complete. 

Age: usually begins after thirtieth year. Usually in childhood; rarely after 

twentieth year. 

Heredity — rare. Frequent. 

Bulbar symptoms not uncommon. Never present. 

over the nerves and muscles, (e) In congenital defects in the pectoral 
muscles and trapezius, any progression is naturally absent, 

Treatment. — Electricity is recommended, but a current sufficiently 
strong to excite the wasted muscles causes too much pain. Massage, 
but especially reasonable exercise, is advisable, because the patients 
begin to fail when they cannot walk. In advanced cases the respiratory 
tract must be watched, since catarrh predisposes to tuberculosis. 



Under diseases of the motor neurones, ophthalmoplegia, Landry's 
paralysis, bulbar palsy, myasthenia, acute poliomyelitis, etc., might also 
be described; these affections, however, are treated elsewhere for 
anatomical or differential reasons. 



III. Combined System Diseases. 

In 1867 Westphal described these affections in paretic dementia, but 
Kahler and Peck in 1877 brought to more general attention this group 
of cases with simultaneous disease in several systems of neurones. Von 
Leyden and Goldscheider consider them diffuse or even myelitic affec- 
tions rather than true system diseases, of which, in their opinion, there 
are but two examples, tabes and progressive muscular atrophy. 

1. Hereditary Ataxia, Friedreich's ataxia (Friedreich, 1861). 
— Etiology. — This affection is hereditary in 33 per cent, and in the 
other instances it is usually familial, although isolated cases are seen. 
Most cases occur in boys. It is held by some to be a congenital hypo- 
plasia of the pyramidal and other tracts, tending to degeneration 



11-36 DISEASES OF THE NERVOUS SYSTEM 

(Friedreich, Schultze, Striimpell), though others regard it as a com- 
bined system disease (Kahler, Pick.) Cerebellar atrophy has been held 
as causal (Senator, Mentzel) but this is more striking in the hereditary 
cerebellar ataxy, described below. 

Pathology. — The cord or medulla, and even the pons are small. 
The earliest and dominant change is atrophy with secondary sclerosis 
of the post, roots and post, columns, and this occurs in Goll's more than 
in Burdach's columns. Lissauer's "root zone" is less affected than in 
tabes, but more than in ataxic paraplegia. The direct cerebellar trad 
and Clarke's gray columns share clearly in the atrophy, as does the ant. 
lat. ascending tract of Gowers. The lot. pyramidal tract suffers in most 
cases, its inner portion being usually normal; the ant. pyramid, tract 
is less altered and principally in the cervical region. Chronic lepto- 
meningitis, sometimes with annular sclerosis of the cord, is occasional. 

Symptoms. — (a) The cardinal sign and the one first observed is ataxia, 
which is less rapid, excessive and stamping (as to gait) than tabetic 
ataxia, and more closely resembles cerebellar ataxia in its tumbling 
character and involvement of the trunk. Static ataxia appears later 
but to a marked degree, and the head oscillates as it does in multiple 
sclerosis, or the arms show jerky movements. Romberg's sign is 
usually present, and the subject leans over to watch his feet; this 
leads to some kyphosis. Testing the sense of location elicits ataxia, as 
in the knee-ankle test. The arms become atactic after a few years. 
Nystagmus develops in most cases, though it is a late symptom; it is 
elicited chiefly on lateral (or upward) movements and is atactic, as is 
also the disturbance of speech, which develops in three to ten years; 
the speech is monotonous,* irregular, unclear, slightly scanning, slow 
and strained; syllables are often elided, the tongue may tremble and a 
nasal twang may be noticed. 

(b) Regarding the reflexes, the knee jerks are decreased early or 
are abolished, being present only in rare atypical cases. The skin, 
pupillary and sphincter reflexes are usually normal. In some (possibly 
syphilitic) cases the pupil reflex may disappear, (c) Other signs 
embrace : Club foot (pes equino-varus) is common, and is best seen 
in the dorsal decubitus; the foot is shortened and widened, the arch is 
exaggerated (pes cavus), the great toe is strongly flexed dorsally 
(extended). Scoliosis and kyphosis are common. Muscular paralysis 
or wasting is rare, although late paraparesis may develop. Sensory 
signs are few; tactile and muscle sensation are sometimes blunted; the 
pain sense is but rarely impaired; paresthesia?, crises, lancinating 
pains, and trophic, vasomotor and sensory disturbances are lacking. 
General or sexual development may be retarded at puberty. The 
pulse is often increased and hsemic murmurs may be heard. Cerebral 
symptoms, as mental dulness, develop late, if at all. 

Course and Prognosis. — About 33 per cent, develops before the 
sixth year, 33 per cent, between the sixth and tenth, and 33 per cent, 
after the tenth year. The atactic gait is the first sign, then speech is 
involved, possibly then the kyphosis and club foot develop, and 



COMBINED SYSTEM DISEASES 1137 

later the arms are affected; the course is steadily progressive, possibly 
with remissions, and the patient becomes bed-ridden in twenty to 
thirty years. Death follows from acute infections, cystitis and sepsis. 

Diagnosis. — The diagnosis is based (a) on the hereditary or familial 
etiology; (6) the age; (c) the ataxia; (d) absent knee jerks; and (e) 
disturbance of speech. 

Differentiation. — 1 . In tabes, there are also ataxia and absent knee 
jerks but in hereditary ataxia, the syphilitic stigmata or history, the 
immobile pupil, eye paralysis, optic atrophy, pains, crises, and vesical, 
trophic and marked sensory disturbances are absent. 

2. Multiple sclerosis (in which there is also speech alteration, 
nystagmus, ataxia and tremor), is differentiated by the history of 
antecedent acute infections, the presence of spasticity, increased reflexes, 
optic atrophy, compulsory laughing and .other psychical signs, apoplecti- 
form insults, a distinctly intentional tremor and slow, scanning speech. 

3. In cerebellar disease the ataxia is similar, but in tumors there is 
optic neuritis, headache, and vomiting. Marie, Londe and Nonne 
described a clinically similar affection, hereditary cerebellar ataxia,. 
which is probably due to simple congenital atrophy of the cerebellum 
(middle lobe), degeneration in Clarke's columns, cerebellar tracts and 
posterior columns, is also hereditary or familial, but develops later^ 
between the twentieth and thirtieth years. The ataxia is cerebellar. 
The reflexes are increased (which Patrick thinks is the sole differentiat- 
ing point), often with spasticity; quite frequently there is optic 
atrophy, limitation of the visual field for objects and color, eye paralysis 
and sometimes an immobile pupil, nystagmus, choreiform movements, 
and moderate sensory and speech disturbance, which may be nasal and 
marked by unequal inspiration and expiration. The club foot, scolio- 
sis and Romberg's sign are absent. Sanger Brown has reported 25 
and J. H. Neff, 13 cases. 

4. Cerebral diplegia of children, and ataxic paraplegia are dis- 
tinguished by reflex increase and spasticity. 

5. "Amaurotic family idiocy" (Sachs, Peterson, Hirsch) is char- 
acterized by paresis or paralysis, idiocy, optic atrophy, marasmus, 
and a rapidly fatal course before the third year of life. At autopsy 
hypoplasia, microgyria, decreased pyramidal cells, tangential and other 
fibers are noted. Sachs observed 27 cases in Jews, and Haveroch (1904 ) 
collected 36 cases. 

Treatment is wholly symptomatic. 

2. Ataxic Paraplegia (Gowers). — Most cases occur in males between 
thirty and forty; cold and concussion are possible causes; syphilis is 
a rare cause. Pathologically, there is a lateroposterior sclerosis; in 
the lat. column the degeneration is not wholly systematic, symmetrical 
or pyramidal; it may invade the mixed zone; in the post, column the 
process is not more intense in the lumbar cord, and is less intense in the 
root zone than is the case in tabes. Sometimes the process is so diffuse 
that it suggests myelitis or arterial obstruction (Marie). The early 
symptoms are those of a gradual spastic paraplegia (muscular weakness, 



1138 DISEASES OF THE NERVOUS SYSTEM 

exaggerated reflexes, moderate rigidity), followed by ataxia (mostly 
in the legs, with Romberg's sign). The arms are involved later, 
though to a less degree. In the last stages the ataxia is obscured by the 
spastic paraplegia; vesical or rectal tenesmus and muscle cramps are 
fairly common. Cranial involvement is infrequent, though sometimes 
suggested by slightly disturbed articulation, nystagmus, tremulous 
facial movements, and increased jaw-jerk. The mind is usually clear, 
though in some cases late dementia develops. Sexual activity is often 
lessened, and the sphincters are sometimes moderately disturbed. 
Dull sacral pain is sometimes observed. 

Differentiation is necessary (a) from tabes. Certain tabetic symptoms 
are absent, as the high-stepping and sudden-stamping gait, the immo- 
bile pupils, optic atrophy, eye paralysis, lancinating pains, crises, 
other sensory disorders and absent knee jerks, (b) Friedreich's ataxia is 
distinguished by the age, heredity, speech, and absence of patellar 
reflexes, (c) Myelitis is more acute, diffuse and later is regressive. 
(d) From simple spastic paraplegia it is recognized by the ataxia. 

The prognosis and treatment are those of spastic spinal paraplegia. 

3. Other Combined System Diseases.— Combined sclerosis may 
be (a) exogenous, as in pellagra (q. v.) with degeneration, and then 
sclerosis of the posterior lateral columns; as in ergotism (q.v.), the 
longest known variety, and in lathyrism (q.v.), or it may be (b) 
endogenous, as in multiple neuritis, diabetes (Williamson), pernicious 
anaemia (Lichtheim), cachexia, icterus, leukaemia (Minnich), brain 
tumor, plumbism, or diphtheria. Some toxin causes degeneration 
which is followed by sclerosis. It was found by Putnam in enfeebled 
middle aged persons, especially in women. Dana, Bastianelli, Batten, 
Russel, and Collier have described similar cases. 

Pathologically, there is posterolateral sclerosis with diffuse or at 
times discrete degenerative foci. All the columns may be affected. The 
most diffuse changes are in the cervical and the least in the lumbar 
cord, and sometimes changes exist in the ant. horns and Clarke's 
columns. There are sensory symptoms (lancinating pains, paresthesia, 
anaesthesia, ataxia), motor symptoms (paresis, paraplegia, choreiform 
movements) or reflex symptoms (the patellars, for instance, being 
exaggerated or even lost, the sphincters incompetent); optic neuritis 
and oedema are occasional findings. 



DISEASES OF THE PERIPHERAL NERVES 1139 



IV. DISEASES OF THE PEEIPHEEAL NEEVES. 

1. Mononeuritis. — Inflammation of a single nerve trunk. 

Etiology. — (a) Injuries, wounds, fractures, dislocations, delivery , vio- 
lent muscular contractions as in blacksmiths; exhaustion or disturbed 
metabolism; anaesthesia (ether) paralyses, the arms being held over the 
head (in the Trendelenberg position), the legs bound in holders, or 
when Esmarch's bandage is applied; ether hypodermatically, malpo- 
sitions of the arm during sleep, and the use of crutches, are causes. 
(b) Contiguous disease (pleurisy, pelvic inflammation, compression 
by tumors, or aneurysm) may produce neuritis, (c) Cold (rheumatic 
paralysis) causes inflammation in the sheath, whence extension to the 
nerve, (d) Toxic causes, as plumbism and alcoholism, and acute or 
chronic infections (v. i. Multiple Neuritis) are factors. 

Pathology. — In acute cases, the nerve is red, swollen, soft, and 
sometimes the seat of punctate hemorrhages or extravasation of 
white cells in the sheath or between it and the nerve fibrils. In some 
cases inflammation involves the sheath chiefly (perineuritis), and in 
others the interstitial tissue (interstitial neuritis) , in which the included 
nerve fibrils are readily compressed. The process is either disseminated 
or focal (where the nerve divides or enters the fascia or bone). In many 
cases the nerve fibrils are most affected (parenchymatous neuritis). It 
is often difficult to distinguish between inflammation and degeneration ; 
in both processes there is nuclear multiplication and protoplasmic swell- 
ing in the neurilemma; this compresses the myelin sheath, which 
becomes varicose, granular, fragmented, shows nuclear increase and 
finally becomes emulsified. The axis cylinder, composed of thirty to 
fifty primitive fibrils, becomes granular, divided and may largely or 
wholly disappear. Regeneration is probably accomplished from the 
spinal or cerebral centres but also from the periphery. 

Symptoms. — Symptoms vary with the intensity, extent and seat of 
the neuritis (see Individual Nerves). Constitutional disturbance 
may attend acute cases. 

1. Sensory Symptoms. — The chief local symptom is pain, ex- 
perienced largely in the sensory nerves, either locally or eccentrically 
over their area of distribution; it is increased by tension or movement, 
is usually intense and is sometimes increased at night. Tenderness is 
referable to involvement of the nervi nervorum (Wier Mitchell). 
Hyperesthesia, hypesthesia and paresthesia may be noted, but com- 
plete anesthesia is rare except for relatively small areas. Sometimes 
the swollen nerve or perhaps nodules (n. nodosa.) may be felt. 

2. Motor Symptoms. — The muscles supplied are tender to touch, 
painful on movement, paretic or paralyzed, and atrophied (separation 
from their trophic centres or loss of reflex connections) . They are nar- 
rower, less clearly striated, granular and finally indurated. Muscular 
contractures may result reflexly, especially in traumatic and professional 
or occupation neuritis. The reaction of degeneration is present. The 



1140 



DISEASES OF THE NERVOUS SYSTEM 



normal nerve is stimulated by the faradic (induced) and by a stronger 
degree of the voltaic (constant) current; the faradic produces a contin- 
ouus muscular contraction and the voltaic produces a contraction when 
the circuit is made or broken, — the cathode closing contraction, which 
is first to appear and stronger than the anode closing contraction. In 
disease, the following changes from normal occur (Church) . (a) The 
muscle responds weakly, sluggishly and deliberately to faradism, and 
tends to maintain contraction after the current is withdrawn. This 
is the modal change, the most essential element in the reaction, (b) "The 
nerve trunk loses progressively and equally its responsiveness to both 
galvanism and faradism — a quantitative change, (c) "The [muscle 
becomes much more excitable by galvanism and much less excitable by 
faradism; the latter reaction and the responses in the nerve trunk [are 
completely lost after two or three weeks. This is the qualitative 



Fig. 77. 



DEGENERATION 
OF NERVE 



ATROPHY AND NUCLEAR 
PROLIFERATION OF MUSCLE 



REGENERATION 

A. 

9 




DEGENERATION 




VOLUNTARY 
MOTION 

f GALVANIC- 

I' + 

S FARADIC 



20 30 4.0 .30 GO 70 80 90 100 WEEK 

incurable paralysis with complete degeneration. (Erb , 



1, paralysis with early return of motion; 2 

modified by Church). 

change, (d) "A polar change appears in the muscle about the second 
week when directly stimulated by galvanism; the muscle is not only 
more readily caused to contract by the constant current, but the normal 
mastering strength of the negative closing contraction over the positive 
has disappeared and the positive closing contraction is equal to or 
greater than the negative" (A. Church). 

In the middle or mixed form of Erb there is a normal reaction in the 
nerves and increased voltaic response in the muscles. 

3. Trophic Symptoms. — The skin is sometimes red, "glossy,'' 
cedematous or more rarely thickened. Increased secretion of sweat, 
eruptions as herpes, erythema or pemphigus, inflammation or adhesions 
in the joints, and perforating ulcers are less common. 



MULTIPLE NEURITIS 1141 

Neuritis may sometimes ascend to the cord or its membranes as in 
traumatic cases or in bladder disease. In rare instances the corre- 
sponding opposite nerves may become involved without disease of the 
cord; this is the so-called sympathetic neuritis. The progressive 
hypertrophic interstitial neuritis of childhood (Dejerine and Sottas, 
1893) is a rare affection, in which there is anatomically sclerosis 
and hypertrophy of the nerves, ant. and post, nerve roots, and sclerosis 
of the post, columns as in tabes, and clinically, muscular atrophy, 
pains, anesthesia, nystagmus, pupils immobile to light, and kypho- 
scoliosis. 

Diagnosis. — Diagnosis depends on (a) localization of symptoms to a 
nerve trunk and its distribution; (6) pain, tenderness and objective 
sensory alteration; (c) muscular atrophy or paralysis; and (d) trophic 
changes. The early diffuse pain may simulate disease of the bones or 
joints. Chronic (sensory) forms may resemble neuralgia, in which the 
pain is paroxysmal, the tender points more localized, the initial tender- 
ness less, and objective sensory alteration absent. Disease of the cord 
or nerve roots usually paralyzes several muscles and affects sensation 
segment ally. 

The prognosis depends on the cause and intensity of the process. 
Acute cases last for weeks; chronic cases, for months. The outlook is 
usually good in traumatic cases, and bad when they are due to con- 
tiguous suppuration. 

Treatment. — The treatment is (a) that of the cause, (b) Absolute 
rest is indicated. Exertion increases just as it may initiate, neuritis. 
(c) Pain should be relieved. The salicylates and iodides are of un- 
certain value. Local heat may relieve, but sometimes causes burns 
and ulcerations, for the anesthetic skin may not perceive its intensity. 
Coal-tar products should be given in preference to morphine, cocaine or 
Schleich's infiltration anaesthesia, because habits may be contracted; 
opiates are necessary in severe cases. The positive pole of the voltaic 
current, just strong enough to be felt, may relieve pain, (d) Paralysis 
should be treated only after the acute stage. The weak interrupted 
voltaic current (not the faradic) is indicated. Massage and later 
passive motion are beneficial largely because the veins from the nerves 
empty into the muscle veins and surround the muscle arteries. 



2. Multiple Neuritis; Polyneuritis, Peripheral Neuritis. This 
affection was described by James Jackson (1822) and Ladd (1854), 
but the first accurate and pathological description was given by Dumeil 
in 1864, while Joffroy, 1879, Leyden, 1880, and Stewart, 1881, made 
important contributions. 

Definition. — Neuritis (or nerve degeneration) due to the selective 
action of toxic substances on the less resistant peripheral nerves, 
causing (a) multiple, symmetrical, bilateral, flaccid, or atrophic 
paralysis with (b) the reaction of degeneration, (c) sensory and (d) 
often trophic disturbances. 



1142 DISEASES OF THE XERYOUS SYSTEM 

Etiology. — The causes are (a) poisons; alcohol is the most important; 
lead, arsenic (in beer), mercury, phosphorus, carbon monoxide, silver, 
aniline and ergot may also produce the disease, (b) The infections, 
(i) acute, as diphtheria, typhoid, sepsis, and also, occasionally, almost 
every active infection, and (ii) chronic, as beri-beri, leprosy, tuberculosis 
or syphilis, are etiological factors, (c) Intoxications, as auto-intoxica- 
tions, diabetes, nephritis, digestive disorders, cachexias and pregnancy, 
may be causal, (d) Other causes include the seemingly primary cases. 
Cold and rheumatism may produce it ; our present knowledge cannot 
explain their mode of action; probably these cases should be classified 
as infectious, for spontaneous multiple neuritis has occurred epidem- 
ically. Arteriosclerosis (of the nerve vessels) is a rarer cause. It may 
occur with tabes. It is a disease of adults (twentieth to fiftieth year) ; in 
children it may occur with poliomyelitis. 

Pathology. — In acute cases the nerve may be red, swollen and the 
seat of punctate hemorrhage, exudation of leukocytes or albuminous 
exudation in the connective tissue, but usually parenchymatous degen- 
eration predominates. It appears first and most markedly in the 
smaller nerves. As in mononeuritis, the axis cylinders waste and the 
medullary sheaths disintegrate. The symmetry and multiplicity of 
degeneration in the nerve endings is caused by the altered condition 
of the blood by toxins or poisons. Acute polymyositis of similar 
origin may accompany neuritis multiplex. In cases which are chronic 
from the beginning, there is slow degeneration of the nerves. The con- 
nective tissue is increased in certain forms, as gouty or leprous neuritis. 
The toxic cause may also produce degeneration of the cord or brain 
and changes in the liver (alcoholic cirrhosis), kidneys (alcohol and 
lead), and lungs. 

Symptoms. — The symptomatology varies considerably with the 
cause. In acute cases it may begin with chills, fever, delirium, headache, 
diarrhoea, icterus, bronchitis, acute splenic tumor, albuminuria or 
other toxsemic symptoms ; these are followed by prodromal numbness, 
tingling, pains, cramps or vasomotor symptoms, while in chronic cases 
the symptoms develop slowly. 

1. Sensory symptoms are usually first to appear, the last to disappear, 
and are throughout the most vexing manifestations. Paresthesia 
precedes pain and pain precedes paralysis. The muscles, nerve trunks 
and skin are the seat of spontaneous pain, tenderness to pressure and 
pain on movement. The palms of the hands and soles of the feet are 
especially hypersesthetic in the tabetic, diabetic and diphtheritic forms. 
Sensation is often blunted, perverted or less often completely suspended; 
the most marked findings exist below the elbows and knees, although 
higher extension, even to the face, is possible. Sensory dulness may 
concern pain, temperature, tactile or muscular sensation. Some sen- 
sory disturbance is rarely absent. Delayed conduction may occur. 
The joints may be painful and swollen, especially in the hand, causing 
thickening and limitation of movement. 

2. Motor symptoms occur chiefly in the peripheral distribution of 



MULTIPLE NEURITIS 1143 

the spinal nerves', they develop first and are most marked in the 
extensors of the leg and foot, forearm and hand, and produce the ankle 
and wrist drop (ext. popliteal and musculospiral nerves). The foot is 
also inverted. The paralysis is flaccid, being rarely attended by 
muscular spasm. If the paralysis is only moderately severe in the legs, 
the "steppage" gait (Charcot) is noted, and the patient lifts the legs 
high to clear the pendant toes ("turkey-gobbler walk"). The paralysis 
later involves the flexors and the muscles of the arm and thigh. The 
muscles may show an early increased irritability to both the galvanic 
and f aradic currents ; this is followed by some or all of the elements of 
the reaction of degeneration (sometimes before paralysis appears, 
Popoff). The muscles rarely fail to respond to the galvanic current, 
even in the extreme cases. Then the muscles atrophy, chiefly in distal 
parts, i. e., where the sensory and motor changes predominate. Other 
motor manifestations are cramps, tremor, fibrillation, ataxia and 
contractures. The patient either lies on the back with the members 
extended or on the side with flexor contractures, which draw the heels 
to the buttocks and the thighs to the abdomen. The trunk muscles may 
be affected as well as those of the neck and eyes, face, tongue, or indeed 
those supplied by any cranial nerve; rapid pulse, palpitation, dys- 
pnoea, and vocal disturbance indicate involvement of the vagus ; optic 
neuritis and amblyopia may occur. Involvement of the cranial and 
spinal nerves is observed in the neuritic form of Landry's paralysis. 
The tendon and skin reflexes decrease and disappear although initial 
increase or exceptional persistence has been noted. The organic 
reflexes are almost always preserved. Involvement of the bladder and 
rectum, which is very rare, is referable to the mental state or to neuritis 
of the pudendal plexus. 

3. Trophic symptoms may be present. The skin is cold, turgid, 
harsh, sometimes glossy; eruptions (herpes, erythema), ulceration, 
bed-sores, and trophic changes in the nails or hair, are uncommon; 
oedema over the wrists and ankles may occur, especially in alcoholics, 
and is trophic or vascular in origin. 

4. There may be general symptoms. Mental symptoms and mal- 
nutrition may result from the antecedent toxaemia or cachexia, pain or 
disturbed circulation. Korsakow and others have described the 
"neuritic psychosis," marked by amnesia, delirium, and hallucina- 
tions, which are probably due to the causes just mentioned. Recovery 
is the rule. Some visceral symptoms have been referred to involvement 
of the cardiac, sacral or pudendal plexuses, although mostly without 
positive evidence. 

Course and Prognosis. — Whether the disease begins acutely or 
slowly, the common order of symptoms is paresthesia, pain, paralysis, 
amyotrophy, trophic and mental symptoms. The distal parts are 
involved more early and intensely than the proximal. In most cases 
recovery requires about a year. Paralysis of the vagus may cause 
death. The prognosis depends in part on the cause. It is good in 
sensory types, and in forms of slow evolution, when the sensorium, 



1144 



DISEASES OF THE XERVOUS SYSTEM 



arms and trunk, cranial nerves and sphincters escape involvement, and 
when visceral disease as liver cirrhosis, cord or brain complications and 
cedema are absent. The prognosis must regard the possibility of 
recurrence (recurrent type) and cover the progress of the disease, 
which is inevitably slow, despite treatment. 

Diagnosis. — Early diagnosis is important, in order that etiological 
therapy may be instituted. The cardinal signs are (a) the motor and 
sensory symptoms, which correspond in function, peripheral distribu- 
tion and symmetry; (b) the reaction of degeneration; (c) tenderness of 
the nerves and muscles; (d) loss of reflexes and (e) the etiology. 

Diagnosis of Type. — (a) The alcoholic form is the most frequent; 70 
per cent, of cases occur in women; the legs are often involved; there is 
the "steppage" gait; sensory and mental symptoms are most marked; 
the atactic form is not infrequent (v.i.); recurrence is probable, (b) 
When due to lead poisoning, the occupation, lead line, colic and con- 
stipation are characteristic; the arms alone are involved as a rule; 
there is little or no sensory participation; the involvement rarely extends ; 
the wasting is conspicuous, (c) Diphtheritic form (q. v.). (d) In the 
toxemic form there is fever, and constitutional reaction; it begins in 
the legs or in all members simultaneously, involves equally the flexors 
and is attended by slight sensory symptoms (Gowers). (e) When due 
to beri-beri (q. v.), vagus symptoms, dropsy and cardiac failure are 
frequent. (/) Leprous neuritis, erythromelalgia and Dercum *s disease 
are considered elsewhere. 

Differentiation. — Atactic polyneuritis (pseudotabes peripherica, 
Dejerine) with little or no motor disturbance, may resemble locomotor 
ataxia : 



Locomotor Ataxia.- 



-Multiple Neuritis. 



History or stigmata of syphilis. 

Argyll-Robertson pupil. 

Optic atrophy, 10 per cent. 

Eye paralysis frequent. 

Early girdle sensation and lightning 

pains. 
Muscular sense early and frequently 

disturbed; ataxia. 
Gait ataxic, stamping, striking heel first. 

Sensory symptoms predominate. 

Paralysis, reaction of degeneration and 
amyotrophy rare. 

Nerve trunks often insensitive. 

Arthropathies, osteopathies, rrval per- 
f or ant. 

Crises. 

Sphincters early and frequently in- 
volved. 

Clinical evolution very slow. 

Disease incurable. 



Rare: history of infection or intoxica- 
tion. 

Absent (loss of accommodation in 
diphtheria). 

Rare, but toxic amaurosis is frequent. 

Much more rare. 

Very rare. 

Rare. 

Gait due to motor more than sensory 
disturbance. Striking toe first. 

Motor predominate. 

In nearly all cases; rapid in develop- 
ment and symmetrical. 

Tender, as are muscles. 

Unknown; glossy skin more common. 

Almost unknown ; toxsemic vomiting, etc. 
Very rarely, if ever, and from delirium, 

etc. 
Rapid. 
Recovery usual, if not early death. 



NEUROMA 1145 

Poliomyelitis. vs. Multiple Neuritis. 

Usually in children. In adults. 

More sudden onset. Less acute. 

Embraces whole limb; random distribu- Peripheral and symmetrical. 

tion. 

Muscles functionating together. Reac- Dissimilar muscles involved. 

tion of degeneration in both, but 

strong galvanic current not required Muscles respond only to strong galvanic. 

(during first months) to produce 

muscular contraction. 

Pain and tenderness most rare. Common in nerves and muscles. 

Sensory disturbance rare. Usually (but not invariably) present. 

Immediate tendency to regress, but al- Tendency to progress. 

ways some deformity. Total recovery the rule. 

In acute myelitis, the onset is acute, there are girdle pains, paraplegia, 
with corresponding anaesthesia, bed-sores, disturbance of the bladder 
and rectum; there is no tenderness of the nerves or muscles, little or no 
ataxia, and recovery is unusual. Landry's paralysis often cannot be 
distinguished (which is natural, as one form of Landry's disease is 
neuritic); sensory, trophic and sphincter changes are absent. 

Treatment. — In the etiological therapy, alcohol must always be 
considered and deception guarded against ; it should be withdrawn at 
once. In sepsis, Gowers gives full doses of iron. For treatment of 
pain see Neuritis. Absolute rest should be enforced.- A full diet, 
rich in fats, should be given if the stomach can tolerate it; tonics 
should be given to maintain nutrition, but arsenic should be avoided. 
When the lower cranial nerves are affected, feeding by the nasal tube 
or by rectum, measures to avoid hypostasis as in typhoid, and cardiac 
stimulants are indicated. To overcome contractures from ankle- or 
wrist-drop, splints or sand-bags should be employed when they do not 
cause excessive pain. The weight of the bedclothes on the feet may 
promote contractures, whence frames to lift the bedding should be used. 
Gentle massage and voltaism may be tolerated after the acute stage, 
may prevent contractures, and may aid the return venous flow. Bro- 
mides and chloral are the most certain somnifacients but chloral must 
be used with care in chronic alcoholism. Orthopedic measures are 
indicated in neglected contractures. 



3. Neuroma. — Two varieties exist, the true and the false neuroma. 
The true neuroma may be medullated, or non-medullated, though 
ganglion cells are exceptional (only 3 cases are recorded) ; they are 
usually multiple, sometimes very numerous (3,020 in one case), and 
have been found in instances on every cranial, spinal, and sym- 
pathetic nerve. They may undergo sarcomatous degeneration. 
The tubercula dolorosa (Virchow) are small, painful, subcutaneous 
nodes on the trunk or extremities, the anatomy of which is not well 
understood. The neuroma plexiforme consists of twisted cords with 
nodes, is congenital and occurs largely in the distribution of the fifth 



1146 DISEASES OF THE XERVOUS SYSTEM 

nerve. The false neuroma is usually fibrous; glioma is rare; sarcoma 
or carcinoma may by contiguity invade adjacent trunks; neuromata 
have been found in the cerebral nerves in syphilis, and in the peripheral 
nerves in leprosy. The nerve trunks suffer more in the false than in 
the true form. Neuromata in amputation stumps are of frequent 
occurrence. 

There may be no symptoms; local tenderness and local or projected 
pain are frequent. Reflex muscular spasm is common from nerve 
irritation. Mentality, sensation or motility may be affected. Pig- 
mentation has occurred. Diagnosis is certain only when the growths 
are felt. Treatment is symptomatic for the exhausting pain, or radical 
in localized growths. Recurrence is not infrequent. 

4. Diseases of Cranial Nerves. 

Olfactory Nerve. — The end nerves of smell are located on the two 
upper turbinate bodies and the upper septum; thence they run to the 
olfactory bulbs, which are really part of the brain. The central 
connections are not well understood. The centre is thought to be in 
the uncinate gyrus and the hippocampus, with relations to the optic 
thalamus, opposite internal capsule and cerebral cortex. The anterior 
nares perceive odors, the posterior, flavors. 

Anosmia is loss of smell. Tests are made not with pungent sub- 
stances, as ammonia, which irritates the fifth nerve, but with musk, 
asafcetida, cologne water and the essential oils, (a) Disease in the 
nasal mucosa is the most frequent cause; it may result from paralysis 
of the fifth nerve, arrest of secretion, or atrophy in old age. (b) 
Disease of the bulb and tract may result from congenital absence of the 
bulb, basal fracture, or meningitis in the ant. fossa, disease of the middle 
cerebral artery, tabes (possibly centric atrophy), hydrocephalus, and 
foci in the opposite internal capsule, (c) Central disease may be 
located in the hippocampus and uncinate convolution, as softening. 
The prognosis is usually unfavorable and treatment is ineffectual. 
Hyperosmia, or oversensitiveness of smell, occurs in insane and neu- 
rotic subjects; it may be cultivated, so that individuals are recognized 
by their odor. Parosmia, or perverted sensation, is rare, and arises 
from irritation of the nerves or centres. Hallucinations of smell may 
occur. Imaginary odors, as of burning flesh, may constitute the 
epileptic aura. 

Optic Nerve. — (A). The Retina. — Retinitis occurs in general 
diseases, as nephritis (in 15 to 25 per cent.), especially in interstitial 
forms, and late in the disease rather than early. The degenerative 
form is most common, the next is the hemorrhagic form, with "flame 
like" hemorrhages along the vessels, and finally the inflammatory type, 
with swelling of the retina, serum exudation, cloudiness and disk 
blurring, which may be as marked as that of brain disease ; the white 
foci which are seen are due to exudation, fatty change or sclerosis. 



PLATE XIX. 




VISUAL 



^ VISUAL*^ 



Visual Paths. (After Vialet.) 

blindness. 



DISEASES OF CRANIAL NERVES 1147 

Similar findings may occur in syphilis, anaemia (Quincke), malaria, 
leukseinia (q.v.) purpura, plumbism, and diabetes (see Plates V and 
VI). There are apparently primary cases. 

(B). Optic Nerve. — Optic neuritis (papillitis, choked disk) has 
been fully described and differentiated (see Brain Tumor and Plates 
V and VI). Tumors or inflammation in or back of the orbit may 
be causal. Errors in refraction must be excluded. In the primary 
form there is no initial inflammation. The edges of the disk are dis- 
tinct, its arteries nearly normal and its color grayish; it may develop 
hereditarily in males at puberty; it occurs in tabes, paretic dementia, 
multiple sclerosis, syphilis (in connection with all of which it has been 
discussed), and less often from exposure, excesses, diabetes, alcoholism, 
plumbism, the specific fevers, amaurotic family idiocy and familial 
cerebellar ataxia. The form secondary to inflammation commonly follows 
choked disk and has the same significance; the disk has an irregular 
contour, small arteries, and is translucent. The symptoms are 
diminution in acuity of vision, field of vision, color perception, and 
the pupillary reaction. 

(C). Chiasm. — Each half of the retina contains fibers from the 
corresponding occipital lobe (see Plate XIX), that is, each right 
half receives fibers from the right, and each left half from the left, 
occipital lobe. The point of sharpest vision, the macula, receives over- 
lapping fibers from both sides of the brain. The outer (temporal) 
portion of the field of vision is more limited than the inner (nasal) 
portion, because the nose cuts off light, and consequently it receives 
fewer nerve fibers. The larger number of fibers from each eye, i. e., 
those from the nasal retinal half, decussate at the chiasm and lie in its 
centre. Those from the temporal half are direct and lie at the side of 
the chiasm. While division or disease of one optic nerve causes blind- 
ness in the corresponding eye, lesions affecting the centre of the chiasm 
(decussating fibers to the nasal half of each retina) cause half blindness 
in the opposite (temporal) visual fields, bitemporal hemianopsia, since 
oblique rays passing the pupil fall on the opposite half of the retina. 
The macula receives fibers from both sides of the brain and therefore 
escapes involvement. Temporal hemianopsia may result from tumors 
of the pituitary gland, pressure from the infundibulum of the third 
ventricle, gummata and hemorrhage. The "oscillating" or varying 
bitemporal hemianopsia is often indicative of syphilis. The diagram 
illustrates effects of lesions of the lateral part of the chiasm (3), lesions 
affecting both sides of the chiasm (3 and 3 A) as calcarious or aneurys- 
matic carotids; tabes or tumors are most rare; binasal hemianopsia 
is therefore most exceptional; a large lesion might produce temporal 
hemianopsia in one eye and total blindness in the other; still more 
extensive disease might produce total blindness; these changes may 
be successive. 

(D). Optic Tract. — Just back of the chiasm the temporal fibers 
of the right and the nasal fibers of the left side form the right optic 
tract, i. e., the right tract contains all fibers from the right half of each 



1148 DISEASES OF THE XERYOUS SYSTEM 

retina. The tract runs over the cms cerebri, where a lesion very often 
causes hemiplegia on the same side as the blind field. The fibers enter 
the geniculate bodies (in which 80 per cent, of the optic fibers end), 
opt. thalamus and ant. quadrigeminate body, from which gray ganglia 
the fibers pass by way of the posterior limb of the internal capsule and, 
by radiating fibers (optic radiation), to the visual centre in the posterior 
internal part of the occipital lobe, the cuneus. A lesion (at 5, in 
diagram) in the optic tract anywhere between the chiasm and cuneus 
produces lateral or homonymous hemianopsia; for instance, if it occurs 
in the right optic tract it produces loss of function in the temporal half 
of the right and nasal half of the left retina, so that the left half of each 
field of vision is lacking. Hemianopsia may be partial and may involve 
only a quadrant, or only a quadrant may remain after partial recovery. 
The unaffected fields may suffer some reduction. Heteronymous 
hemianopsia designates blindness of the right half of one field and the 
left half of the other, or the converse. Disease in the gray ganglia or 
internal capsule may produce contralateral hemiplegia: indeed in 50 
per cent, of cases of hemianopsia this association is observed, and less 
frequently hemianesthesia. Transient hemianopsia is sometimes seen 
in migraine. The optic tract is injured in tumors, multiple sclerosis 
trauma, hemorrhage or softening. 

(E). Optic Centre (see Cerebral Localization). — A lesion in 
the cuneus produces (a) homonymous hemianopsia. Sometimes only 
an upper quadrant is blind (disease in the upper part of the cuneus) or 
the lower quadrant is blind (disease in its lower part). Purely cortical 
hemianopsia is impossible, and Monakow held that the optic radiation 
must be involved; (b) hemichromatopsia, or homonymous color blind- 
ness or confusion, in which all colors seem gray, is propably due to 
lesion of the anterior superficial cuneal cortex. Other results are (c) 
mind blindness, or loss of visual memory; (d) alexia or word blindness; 
(e) optic aphasia; and (/) crossed amblyopia, concentric blurring or limi- 
tation of the visual fields for form and color; this is usually referred, 
however, to disease of the gyrus angularis, in which there is thought to 
be a higher centre in which the half fields are combined and the whole 
opposite field and part of the field of the same side are represented. 

Diagnosis. — The eyes should be tested separately. Disease of 
an optic nefve causes loss of sight and pupillary reaction in the corre- 
sponding eye. Central scotoma (blindness in the centre of the visual 
field) indicates inflammation or hemorrhage in the central (axial) 
fibers of the nerve, usually back of the orbit; it is common in poisoning 
from tobacco and alcohol. Peripheral limitation of the visual fields 
indicates damage to fibers coursing in the periphery of the optic nerve 
and some damage to all the nerve fibers. Sectorial blindness indicates 
a pronounced but circumscribed affection of the nerve. Bitemporal 
hemianopsia always results from chiasm disease; unilateral temporal 
hemianopsia in one eye with complete blindness in the other has the 
same significance, but also implies that the process has extended 
laterally, possibly even to the optic tract. Lateral homonymous hemian- 



DISEASES OF CRANIAL XERVES 1149 

opsia indicates disease of the optic tract between the chiasm and cuneus. 
If the geniculate (or quadrigeminate) bodies are the seat of the lesion, 
Wernicke's hemianopsic pupillary reaction is obtained, because the 
pupil reflex, while not at present perfectly understood, implies that the 
retina, the optic nerve, the centre and fibers of the third nerve and the 
iris are intact. A small beam of light in a dark room should be thrown 
on the hemianopsic half of the retina, and the patient should look at a 
distance to eliminate accommodation. If the pupil does not react to 
light on the blind half, Wernicke's reaction indicates that the disease 
focus lies at or somewhere to one side of the geniculate (or quadrigem- 
inate) bodies. If the lesion lies between these gray ganglia and the 
cortex, the reaction of Wernicke is absent. Transient hemianopsia is 
common in vascular lesions ; if it lasts for weeks it will probably remain. 
In Sequin's case it was present for twenty-three years. It may occur in 
migraine and very rarely in hysteria. Its association with the crus, 
internal capsule or cortex % symptoms which have been already con- 
sidered is of localizing importance. Amblyopia and concentric limitation 
in the fields, marked in one eye and less in the other, may result from 
(a) optic atrophy, with the absent pupillary reaction, and seen with 
the ophthalmoscope; (b) disease of one hemisphere, the ophthalmo- 
scopic finding and pupillary reflex being normal, (or (c) possibly 
functional disease). 

Functional and toxic blindness may result, (a) Hysterical blindness 
is transitory, and is rarely complete (it is clear that the eye functionates 
normally though the visual centre neglects the impressions) ; it is often 
associated with loss or inversion of the color perception and often with 
hemianesthesia. (6) In amblyopia from tobacco, vision is gradually 
impaired in both eyes, largely as central scotoma with invariable loss of 
perception for red and green colors; the fundus is usually normal but 
sometimes congested; recovery is usual, but atrophy may result, (c) 
Toxic amaurosis , usually transitory, may occur from uraemia, poisoning 
by lead, alcohol, or quinine, syphilis, acute anaemia, and irritation of 
the fifth nerve. 

Ocular Paralysis; Third, Fourth and Sixth Nerves.— General Etiol- 
ogy. — (a) Trauma to the eye, orbit or base may cause ocular paralysis ; 
it is characterized by a slow course and often imperfect recovery, (b) 
Compression by tumors in the orbit which often produce exophthalmos; 
tumors at the base, aneurysm, and rarely hemorrhage into the nerve 
sheath may produce it. (c) Neuritis produced by the above factors, 
orbital cellulitis, meningitis, syphilis, cavernous thrombosis, alco- 
holism, and rheumatism, which is made to cover many obscure cases, 
may be etiological factors. Neuritis may also result from acute infec- 
tions, as diphtheria ; exophthalmic goitre, plumbism and diabetes are 
rarer causes, (d) Nuclear disease is usually due to chronic wasting- 
disease, as in tabes, multiple sclerosis or bulbar palsy, but it is some- 
times acute from polio-encephalitis or vascular lesions, (e) Supra- 
nuclear disease (v. i. Conjugate Deviation) may be a cause. (/) In 
rare cases there is a myopathic form, as in muscular dystrophies. 



1150 DISEASES OF THE NERVOUS SYSTEM 

Anatomy and Physiology of the Motor Nerves of the Eye. — The nerve 
supply is by the sympathetic (which through the ciliary ganglion dilates 
the pupil) and by the third, fourth and sixth cranial pairs, which arise 
from the middle ventricle, Sylvian aqueduct and fourth ventricle, and are 
arranged as follows from before backward : (a) the third nerve nucleus 
with first the ciliary and behind it the pupillary centre, then its muscles 
in this order: the internal rectus, levator palpeb. superior, inferior 
rectus and inferior oblique; (b) fourth nerve nucleus for the superior 
oblique, lying close to the third nucleus, and (c) nucleus of the sixth 
nerve for the ext. rectus. Their connection with the motor cortex 
(and possibly with the occipital and parietal lobes) is through the 
internal capsule and corona radiata. The third nucleus is connected 
with the seventh; winking and movements of the eyelid are thus 
associated with the pupil reaction and accommodation. The action of 
the various muscles is indicated by their names but convergence is 
supplemented by the sup. and inf. recti and the two oblique muscles. 
The inf. oblique turns the eye upward, the sup. oblique downward. 
The upper lid is raised by the levator palp. sup. (acting usually with the 
sup. rectus) and by Miiller's muscle. 

Paralysis of the Third Nerve. — This nerve emerges from the 
crus and follows the cavernous sinus, and therefore may be involved in 
disease of these structures. A complete paralysis involves all muscles 
save the external rectus and sup. oblique, and results in drooping of the 
lid (ptosis), which the patient attempts to overcome by overaction of 
the frontalis. The eye can be moved only outward and a little down 
and inward. Accommodation is lost, the pupil is wide from the un- 
opposed action of the sympathetic nerve and does not react to light. 
There is double vision from divergent strabismus, due to action of the 
unrestrained ext. rectus muscle. Paralysis is often partial, for the 
levator palp. sup. may escape involvement or be affected alone or with 
its associate (the sup. rectus), especially in bilateral nuclear disease. 
Ptosis may be (a) part of an ordinary oculomotor palsy; (b) part of 
a chronic ophthalmoplegia (v. i.); (c) reflex in rare cases of trigeminal 
irritation as from disease of the teeth; (d) myopathic as in muscular 
dystrophy; (e) a result of sympathetic paralysis, false or pseudo- 
ptosis (with a red, hot, cedematous skin, slight recession of the eyeball, 
and contracted pupil); (/) an incurable congenital form, usually 
partial and bilateral; (g) a transient form, observed in the morning in 
women, in which there is usually a good prognosis; (h) an hysterical 
form, usually bilateral, in various associations with the sup. rectus, 
inf. or int. rectus, the eyebrow being frequently lower on the side of 
ptosis. 

Internal oculomotor palsy includes cycloplegia and iridoplegia. (a) 
Cycloplegia (paralysis of the ciliary muscle) results in loss of accommo- 
dation. Near vision is poor; distant vision is good; extreme myopia 
or presbyopia make its detection difficult. Isolated cycloplegia in one 
eye may indicate disease of the lenticular ganglion, in both eyes it is 
nuclear, as in diphtheria or tabes, (b) Iridoplegia may assume three 



DISEASES OF CR AXIAL NERVES 1151 

forms (Gowers). The first is loss of associated action, accommodation 
iridoplegia, in which there is no pupillary narrowing in the act of 
accommodation. It is due to the same causes as cycloplegia and is 
usually but not always associated with it. The second is loss of the 
light reflex, reflex iridoplegia, the Argyll-Robertson pupil, which is 
seen especially in tabes and paretic dementia (very seldom in softening, 
tumors, senile atrophy, hydrocephalus or congenitally). The reflex 
occurs through the optic nerve, optic tracts, corp. quadrigemina or 
corp. geniculata, anterior part of the oculomotor nucleus, probably 
the second branch of origin of the third nerve, its trunk, the ciliary 
ganglion, and its nerves. The pupils are often equally affected and small 
(spinal myosis) but may be unequal (aniscoria, which is also observed in 
some normal persons) . If the pupils are not small, cutaneous iridoplegia 
is not present. The third form is loss of the skin reflex, the cutaneous 
iridoplegia of Erb, in which the normal dilatation of the pupil upon 
pinching, sticking or f aradizing the skin of the neck is lost. It indicates, 
in general terms, disease in the cervical sympathetic nerve, in the fibers 
between it and the cervical cord, diseases of the cord, especially those 
affecting sensation, or of the centre, probably situated in the corp. quad- 
rigemina just outside the light reflex centre in the trunks of the first 
and third nerves. The seat of lesion is probably nuclear, unless special 
localizing symptoms indicate some other localization. Specifically it is 
characteristic of tabes, paretic dementia or syphilis. 

Recurrent or periodic palsy, to which Gubler (1860) and Mobius 
particularly drew attention, is a rare form, involving chiefly most (or 
possibly only one branch) of the third nerve, and rarely the sixth nerve. 
It occurs chiefly in women. At intervals of months to years, possibly 
throughout life, a recurring paralysis develops, lasts a few days (two 
to fourteen) or weeks and then disappears. Forms which begin with 
headache, pain and vomiting were called ophthalmoplegic migraine by 
Charcot. Its nature is unknown. It is probably peripheral in form 
(Mauthner), although Mobius thinks it is nuclear; von Monakow 
considers that its usual cause is organic, as from tumor, meningitis or 
tubercle; the lesion affects the eye nerves (or centres) and also the 
descending branch of the fifth nerve; some few cases are seemingly 
hysterical. 

Paralysis of the Fourth (Trochlear) Nerve. — The superior 
oblique muscle moves the eye downward and somewhat inward. Its 
paralysis is hard to recognize, but it is of little clinical importance. In 
attempts to converge downward the normal inward rotation of the 
eyeball is lacking. 

Paralysis of the Sixth Nerve. — The eye cannot be moved out- 
ward, and is rotated inward by the unopposed internal rectus, marked 
diplopia resulting. This nerve is frequently involved, because of its long 
and exposed course. The nerves of the eye are involved in the following 
order of frequency: 1, ext. rectus; 2, sup. oblique; 3, inf. rectus; 4, 
sup. rectus; 5, int. rectus; 6, inf. oblique (von Graefe). 

Combined Eye Paralysis. — Convergence and accommodation 



1152 DISEASES OF THE NERVOUS SYSTEM 

are associated functionally and their centres lie adjacent, whence they 
are often lost together. The internal recti may fail to contract together 
but may move separately in lateral eye movements. Conjugate devi- 
ation-may occur (see Brain Hemorrhage and Pons Localization); 
if a lesion occur above the sixth nucleus, the eyes cannot be directed 
toward the side of lesion, and are, therefore, directed toward 
the paralyzed side; if the lesion is at the sixth nucleus, the 
sixth nerve on that side is paralyzed, often also the seventh, and the 
opposite third nerve is paralyzed, not from lesion in the third nucleus 
but from the fact that each third nucleus receives afferent impulses 
from the contralateral sixth nucleus for associated eye movements. 

Symptoms. — The general symptoms of paralysis of the eye muscles 
are five (Gowers): 

1. Limitation of movement in the paralyzed muscle, followed by 
secondary contraction of the unresisted opponent. The habitual 
position of the head corresponds in every way to the physiological 
action of the paralyzed muscle (Landholt). 

2. Strabismus (squint), causing lack of parallelism in the visual 
axes, which are divergent when the int. rectus and convergent when the 
ext. rectus is affected; this constitutes the primary deviation. 

3. Secondary deviation is the extra movement of the sound eye in 
its efforts to see, due to its increased innervation, detected by testing 
with the diseased eye closed, or by testing with ground glass over the 
sound one. 

4. Erroneous projection in the paralyzed eye. Distance is normally 
judged by the position of the eyeballs and muscles, and therefore when 
secondary deviation from excessive innervation of the sound muscles 
occurs, it gives the mind an impression of distance greater than is 
actually the case. 

5. Diplopia (double vision) results from failure of the visual axes 
to correspond. The sound eye sees the true image, while the paralyzed 
eye sees the false one, which is less clear, since the image falls on a less 
sensitive retinal area. When the images are either near together or else 
widely separated, the false one may be " neglected." Erroneous pro- 
jection and diplopia always produce vertigo at first. If the false image 
is on the same side of the true image as the eye by which it is seen, the 
diplopia is simple or homonymous; if on the other side, it is crossed or 
heteronymous. The eyes are tested by holding red glass before one eye 
and testing vision with a strip of white paper. If the red image and 
covered eye are on the same side the diplopia is simple; if on opposite 
sides, it is crossed. When the eyes converge it is simple, when they 
diverge it is crossed; i.e., "when the prolonged visual axes cross, the 
diplopia is not crossed." Holding the test object stationary and the 
head being turned in one way or another, in some directions the images 
converge or perhaps blend, while in the opposite direction they separate. 
"The affected eye is that one in the direction of whose image the diplo- 
pia increases; the paralyzed muscle is the one which would give to 
the eye the direction of the false image" (Landholt). Monocular 



DISEASES OF CRANIAL NERVES 1153 

diplopia is almost invariably hysterical (unless there is disease of the 
eye media or error in curvature). 

Treatment. — Treatment is often unsatisfactory from the etiologi- 
cal standpoint. Surgical interference is sometimes indicated. Syphi- 
litic forms (q. v.) may respond to specific treatment, but often recur or 
become permanent. In subacute or acute forms, counterirritation back 
of the ear by blisters, leeches or hot fomentations is indicated. Some 
find mercury useful in peripheral forms. Galvanism is the best form of 
electrotherapy, but may be painful and is seldom beneficial. Prisms 
and tenotomy are sometimes helpful. 

Progressive Nuclear Ophthalmoplegia (Nuclear Palsy). — This 
disease was first described clinically by von Graefe (1856) and later 
pathologically by Hutchinson and Gowers. The etiology is not clear. 
Wernicke and Siemerling found syphilis causal in 17 per cent., which 
estimate is too low according to Hutchinson. Lead, alcohol, and 
toxaemia as from diabetes, grippe, or diphtheria, are possible causes. 
A few cases are hereditary or congenital. Most cases develop in males 
under thirty years of age. The pathology usually consists of degener- 
ative nuclear atrophy resembling that of bulbar paralysis; sometimes 
slow compression or meningitis is found or much more rarely no 
anatomical alteration is detected; this is the so-called functional form. 

Symptoms. — The symptoms are those of a slowly progressive par- 
alysis of the eye muscles; ophthalmoplegia is called external when it 
involves the extrinsic muscles, internal when it involves the pupil, or 
total when both are concerned. The eye muscles are successively 
affected, but in no given or invariable order, until many or all of them 
are implicated. The expression, the fades of Hutchinson, is peculiar, 
being staring, from immobility of the eyeballs, or sleepy from the partial 
bilateral ptosis. Diplopia is quite uncommon, or at the most only 
an early symptom, because of the chronicity of the process. Associated 
muscles are often affected by groups, because of their successive 
nuclear involvement (v. s. Anatomy) ; as the pupil and convergence, one 
internal and the opposite external rectus, the two internal recti, and the 
sup. rectus and the levator. Chronic ophthalmoplegia may be associ- 
ated with the quite analogous bulbar paralysis or progressive spinal 
muscular atrophy; with optic atrophy or with double facial paralysis 
(the rare and obscure infantile or congenital oculofacial paralysis, 
without pupillary involvement, of which Mobius has collected 44 
cases) ; it may be a part or a precursor of tabes, paralytic dementia, or 
multiple sclerosis. 

Diagnosis. — Nuclear involvement is probable when there is (a) 
partial and bilateral ptosis; (b) no involvement of the pupil; or (c) 
involvement of one or more conjugate groups. The lesion may be 
supranuclear, when the head and limbs are involved, exceptionally 
when there is isolated convergence paralysis or paralysis of up-and- 
down movements with ptosis. Sudden apoplectiform nuclear palsy 
from basilar thrombosis is usually asymmetrical, acute and often 

73 



1154 DISEASES OF THE NERVOUS SYSTEM 

associated with hemiplegia. Wernicke's acute superior poliencephal- 
itis is likewise distinguished by its acuity, and toxsemic symptoms as 
delirium. Total or partial ophthalmoplegia may result from syphilitic 
meningitis, polyneuritis, tumors (corp. quadrigem.) or orbital disease, 
but they are generally distinguished by their relatively acute course 
and concomitant symptoms. 

Prognosis. — The disease is very chronic, possibly lasting twenty to 
forty years and is usually progressive. Arrest is possible, but can never 
be predicted. The disease itself causes little risk to life, but its as- 
sociates are dangerous, as tabes or psychoses, which develop in 18 per 
cent. 

Treatment. — Treatment is generally ineffectual. Iodides and mer- 
cury are useless in nuclear disease, but may be given if the localization 
is not definitely known. Strychnia and galvanism usually produce little 
result. 

Sympathetic Paralysis. — This disease was first described by Horner; 
it produces myosis, which is due to paralysis of the dilator iridis, 
and slight ptosis, due to paresis of Muller's muscle. The ocular 
tension is decreased, the cheek is wasted, and the skin is reddened and 
of higher temperature than normal. Irritation of the sympathetic is 
characterized by wide pupils, widening of the interpalpebral space 
and by exophthalmos. 

Ocular muscular spasms occur in conjugate deviation, irritation of 
their nerve trunks when compressed by tumor, and rarely in chorea, 
facial tic, and spasmodic torticollis. In hysteria the eyes may be rolled 
upward and to one side, concealing the iris, or they are often fixed in 
convergence; they never diverge; there may appear to be ptosis, which 
is really spasm of the orbicularis. Convergent spasm may also occur in 
hypermetropia, and divergent spasm in myopia. Isolated spasm of the 
levator palpebrse may occur in irritation of the cervical sympathetic 
nerve, in advanced years, in Graves' disease, and in irritation of the 
fifth nerve. Secondary deviation (v. s.) is spasmodic, as is also nystag- 
mus, which latter consists of rapid, rhythmic, clonic, involuntary 
oscillations, due to muscular spasm with alternating contraction of the 
opposing muscles. It is continuous, as distinguished from the " tremor 
of weakness" which occurs in paretic muscles on movement. It is. 
usually horizontal, less often rotatory and but rarely vertical. Its 
physiology is not understood, but it is probably centric. The causes 
are (a) disease of the eye, as opacities and choroiditis; (b) it occurs 
very frequently in albinos, and (c) in miners, from working with the 
head down and eyes strained to one side, (d) It also occurs in numer- 
ous, usually degenerative nervous diseases; as a cardinal sign in 
multiple sclerosis and Friedreich's ataxia, as a common sign in tumor 
of the cerebellum, corp. quadrigem. and opt. thalamus, occasionally 
in meningeal inflammation or hemorrhage, sinus thrombosis, brain 
hemorrhage or softening, and very rarely in hysteria. 



DISEASES OF CRANIAL NERVES 1155 

Fifth Nerve (Trigeminus; Trifacial Nerve). — The nerve originates 
from its motor nucleus in the pons, from fibers (which are probably 
motor) descending from beneath the corpora quadrigemina, and from 
sensory fibers ascending from the medulla. It is connected with the 
motor cortex and with the cerebellum. The motor and sensory fibers 
leave the pons separately and join only after the sensory trunk has 
passed through the Gasserian ganglion. The Gasserian ganglion has 
three branches; (1) which passes to the orbit by the sphenoidal fissure, 
supplying the skin of the forehead, anterior scalp, upper lid, bridge, and 
top of the nose; it is connected with the cervical sympathetic nerve; 
(2) which passes by the foramen ovale to the sphenomaxillary fossa to 
supply the upper and lower lid, cheek, fore part of the temples, side of 
the nose, upper teeth, gums, pharynx, tonsils, soft palate, uvula and 
roof of the mouth; it has connections with the facial nerve by the 
Vidian, and with the sympathetic nerve; (3) which passes by the fora- 
men rotundum and sphenomaxillary fossa to the rest of the temples, 
anterior and upper part of the ear, auditory meatus, lower cheek near 
the mouth, lower lip, lower teeth, gums, chin, tongue, mucosa of the 
mouth, salivary glands, and as a motor nerve to the muscles of the 
lower jaw, temporals, masseters, pterygoids, mylohyoids, and post, 
belly of the digastric muscle. The lingual branch gives off the chorda 
tympani which joins the facial nerve. From the otic ganglion arises the 
small superficial petrosal nerve which connects with the facial nerve and 
ends in the tympanic branches of the glossopharyngeal nerve. 

Causes of Paralysis. — (a) Lesions of the cortex may produce it in 
very rare cases, (b) Focal disease in the pons, especially of the nerve- 
root fibers, as hemorrhage, and tumors may cause it and much less 
often degenerative lesions as tabes or bulbar paralysis, (c) It may 
result from diseases of the base, as syphilis, meningitis, tumors, caries 
or aneurysms, (d) Affections involving any of the three branches, as of 
the first branch by cavernous thrombosis, pituitary tumor, aneurysm 
or orbital disease, or of the second and third branches by lesions in the 
sphenomaxillary fossa may cause paralysis, (e) Trauma, puncture or 
bullet wounds, but rarely fractures, and (/) infrequently neuritis, un- 
less it is secondary, are causal. 

Symptoms. — 1. Sensory Portion. — Anaesthesia, which is gener- 
ally unilateral, is found in one or all branches, and tactile sensation is 
more involved than the sense of pain. It is often preceded by tender- 
ness along the nerves, irritation or neuralgia. In complete cases, the 
skin and mucosa of the mouth, nose and conjunctiva are anaesthetic. 
The tongue is furred on its anaesthetic half, because the food is not 
chewed on that side. The conjunctival reflex is abolished. The 
secretions are increased by irritation or decreased by paralysis. Smell 
is blunted, and taste (v. i.) is lost. Sometimes there is redness, cyanosis 
or swelling of the face, or the teeth may be loosened. Two trophic 
manifestations are especially important. The first is neuroparalytic 
ophthalmia, which may run beyond simple inflammation of the eye into 
ulceration or complete loss of the bulb; it is due not simply to con- 



1156 DISEASES OF THE NERVOUS SYSTEM 

junctival anaesthesia, which may lead to inflammation because of for- 
eign particles remaining unnoticed in the eye, but is rather due to 
irritation of the fifth nerve, especially of the Gasserian ganglion or 
nerve trunks anterior to it. (It has not occurred, however, in many 
cases in which the ganglion has been surgically removed.) It is rare in 
lesions of the pons. The second is herpes zoster, which is most common 
in disease of the first branch, results from irritation of the Gasserian 
ganglion or the nerves just anterior to it, is often preceded by pain and 
hypereesthesia, and sometimes leads to iritis or ophthalmitis. The 
relation of trigeminal disease to hemifacial atrophy will be considered 
below, under the latter head. 

2. Motor Portion. — Placing the fingers on the temporal and 
masseter muscles, when the patient attempts to close the teeth, reveals 
their failure to contract. Paralysis of the ext. pterygoid is shown (a) 
by failure to move the jaw toward the sound side and (6) by deviation 
toward the paralyzed side, when the jaw is depressed. The muscles 
waste, but they are rather too deep to distinctly elicit the reaction of 
degeneration. The mylohyoid and digastric muscles cannot be sepa- 
rately tested and the role of the tensor tympani and tensor palati 
in trigeminal paralysis is still in dispute. 

3. Gustatory Portion. — The sense of taste covers only bitter, 
sweet, sour, salty and metallic substances, while flavors are recognized by 
the olfactory nerve. The tip and edges of the tongue detect saltiness or 
sourness; the base of the tongue, bitterness and sweetness. It is often 
stated that the fifth nerve supplies the anterior two-thirds of the tongue 
and the glossopharyngeal nerve the posterior third and the palate; 
but disease of the glossopharyngeal nerve alone does not destroy the 
sense of taste. In a study of 26 cases of extirpation of the Gasserian 
ganglion, Cushing decides that taste is only temporarily lost and that it 
does not travel by the fifth nerve. Disease of the lingual nerve (from 
the fifth), after the chorda tympani joins it, produces loss of taste 
(ageusia); disease of the lingual above the juncture or disease of the 
central part of the fifth in the pons does not result in loss of taste. It is 
thought that the gustatory fibers of the fifth run with the chorda to the 
seventh nerve which they leave by the petrosal nerve to again reach the 
fifth through Meckel's ganglion. It is interesting to note that anaes- 
thesia of the tongue may result from facial neuritis and disease of the 
middle ear. 

Diagnosis. — The diagnosis is usually easy when there are symptoms 
in the motor or sensory nerves. Organic irritation characterized by 
pain alone may be difficult or impossible to differentiate from trifacial 
neuralgia, although Gowers holds that there is less radiation and more 
hyperesthesia in organic irritation. The localization must be deter- 
mined. When all branches are anaesthetic, the disease probably lies at 
the base of the brain or in the Gasserian ganglion. In disease of the 
middle" part of the pons, the first division alone may be affected; in 
disease at its side all divisions are involved, often with implication of 



DISEASES OF CRANIAL NERVES 1157 

the third and sixth, or less often of the seventh and eighth nerves. 
Cortical lesions are extremely uncommon. 

Treatment. — Counterirritation over the occiput or mastoid is in- 
dicated by an inflammatory causation, but no irritatant should be 
applied over the anaesthetic areas themselves, lest ulceration occur. 
Galvanization is said to be beneficial. Gelsemium, cocaine and mor- 
phine must at times be used because of severe pain, but the acquisition 
of drug habits must always be borne in mind. The eye should always 
be watched, and boric acid and castor oil be dropped in several times 
daily. Antisyphilitic remedies should be tried in every doubtful case. 

Masticatory Spasm. — The masticatory spasm of Romberg is not 
common. In the tonic type (trismus) the spasm is usually bilateral, 
and the tense muscles are hard and may be tender. The cause may be 
tetanus, hysteria, epilepsy, tetany, tumor in the pons, cortical hemor- 
rhage, or it may be reflex from trigeminal irritation as from dental 
caries. The clonic type is rare and may be serial or intermittent; 
chattering of the teeth is an example. It may occur in chorea, epilepsy 
or hysteria. Grinding of the teeth occurs in paretic dementia, menin- 
gitis or typhoidal states. In diagnosis, tumor, inflammatory irri- 
tation and disease of the temporomaxillary joint must be considered. 
Treatment consists of tonics in nervous subjects, galvanization, blisters 
in hysteria, and the local use of morphine and cocaine. 

Progressive Hemifacial Atrophy. — This affection, first described 
by Parry (1825), is rare, only 135 cases having been reported up to 
1900. Its pathogenesis is not clearly understood, but it is classified 
under disease of the fifth nerve because the only autopsy on record, by 
Mendel, showed neuritis of the ascending root of the fifth nerve. Mo- 
bius holds that acute infections, as measles or scarlatina, are causal, 
because some virus enters through the skin or tonsils and results in 
atrophy. The essential change is a hemifacial atrophy, which develops 
most often in persons between ten and fifteen years of age, in girls (66 
per cent.), and in about 60 per cent, of cases affects the left half of the 
face. In perhaps a half-dozen cases the atrophy was bilateral. There 
may be premonitory pains, hyper- or paresthesias, but the cardinal sign 
is atrophy of the skin, which may show initial infiltration. The skin is 
decolorized and shrunken, its fat disappears, and later in the disease the 
muscles waste and the rough skin lies directly on the bone. The hair on 
the affected side loses its pigment and may fall out, the eyebrows and 
beard especially, sweat secretion is lessened or absent, and the mouth, 
if involved, is drawn toward the side of lesion. The bones on the 
affected side waste, especially in young subjects, most notably the 
maxillae, but even the smaller bones and nasal cartilages are involved. 
On the wasted side there may be no vasomotor reaction ; sensation is 
usually normal, although pain or paresthesia may be noted in the dis- 
tribution of the trifacial nerve. The tongue, tonsils and palate are 
rarely involved. The course is very chronic and practically always pro- 



1158 DISEASES OF THE NERVOUS SYSTEM 

gressive, although remission is possible. The outlook is hopeless and 
there is no treatment other than administration of thyroid extract and 
the injection of paraffin by the Gersuny method, to lessen the facial 
deformity. 

Hemifacial hypertrophy, of which 13 cases only are on record, affects 
largely the cheek; Werner collected 9 congenital cases. Irritative 
neuritis is its suspected cause. 

Seventh or Facial Nerve. — The face is represented in the lower 
Rolandic cortex, whence the fibers run through the corona, internal 
capsule, crus and pons (q.v.), where they decussate and enter the 
nucleus of the opposite side. The nucleus lies in the floor of the fourth 
ventricle inside of the ascending branch of the fifth nerve and receives 
fibers from the third nucleus above for the orbicularis of the eye (where- 
by ocular movements, winking and accommodation are coordinated) 
and fibers from the hypoglossus below for the orbicularis oris (whereby 
correlation of lingual and labial movements is effected). It curves 
around the sixth nucleus, emerging near the juncture of the pons and 
medulla, and enters the auditory meatus with the eighth nerve, bends 
sharply, and presents a ganglionic swelling which receives the large 
superficial petrosal from the Vidian nerve, containing fibers of taste 
from the fifth nerve. These latter again leave the facial nerve by the 
chorda tympani. In the Fallopian canal the facial nerve gives off 
branches as follows: (a) a motor branch to the tympanic plexus; (b) 
a motor twig to the stapedius muscle; (c) the chorda tympani nerve with 
secretory branches to the salivary glands. Passing through the stylo- 
mastoid foramen, it supplies (i) a few sensory branches to the external 
ear; (ii) motor fibers to the external auricular muscles; (hi) motor 
fibers to the posterior part of the occipitofrontalis, and in the parotid 
gland, (iv) breaks up into branches which supply all the muscles of the 
face, the platysma, stylohyoid and post, belly of the digastric. 

Peripheral facial paralysis (mimetic facial paralysis, prosoplegia, 
Bell's paralysis, Bell, 1830) is the most frequent peripheral palsy. 

Etiology. — 1. Neuritis is the most common cause. Exposure to 
cold ("refrigeration," "rheumatism") produces 73 per cent, of cases 
especially in men between the twentieth and fortieth years, and pro- 
duces a perineuritis which compresses the nerve trunk. Angina, gout, 
diabetes, diphtheria, typhoid, erysipelas, mumps, sepsis and other 
infections are occasional causes. 

2. Disease of the petrous portion of the temporal bone (6 to 9 per 
cent.), especially caries and otitis media in childhood, may cause paraly- 
sis. The danger is usually proportionate to the extent of the bone 
disease, but infective matter may reach the nerve by way of the vessels. 
Eighty-three per cent, of cases of disease of the labyrinth cause facial 
paralysis. 

3. Trauma causes 6 per cent, of cases, as paralysis which results from 
basal fracture by tearing, hemorrhage, inflammation or undue for- 
mation of callus; much more rarely from meningeal or cerebellar 
hemorrhage at birth; from the use of obstetrical forceps, and from 



DISEASES OF CRANIAL NERVES 1159 

trauma to the jaw or surgical operations on the parotid gland. Facial 
paralysis may occur in "head tetanus" (E. Rose). 

4. If it results from lesions at the base, it may be due to syphilis (3 
per cent.), which should always be considered when the cause is intra- 
cranial; it is however, less common than the usual descriptions would 
indicate; syphilis rarely causes a peripheral facial paralysis. Aneu- 
rysm, tumor, meningitis and hemorrhage are next in frequency and 
nearly always involve simultaneously the closely contiguous eighth 
nerve. 

5. In the pons, the root fibers or nucleus may be affected, usually 
with the sixth nerve of the same, or the arm and leg of the opposite side. 
Degenerative affections, as tabes, bulbar paralysis, multiple sclerosis, 
and progressive muscular atrophy or acute poliencephalitis rarely invade 
the seventh nucleus. 

6. Other rarer factors are primary hemorrhage into the Fallopian 
canal, disease of the parotid or lymphatic glands, and leuksemic in- 
filtration. It is suggested by Neumann that disease of the lymph 
vessels at the point of exit of the facial nerve may produce paralysis. 

Pathology. — Few autopsies have been made on simple cases. The 
nerve has been found severed, its sheath and cylinders destroyed, the 
nuclei in Schwann's sheath increased, the connective tissue increased 
and the muscles the seat of fatty change. It is thought that the essen- 
tial and usual change is a perineuritis and that the exudation in the 
sheath compresses the nerve fibers, which then undergo parenchy- 
matous degeneration. In some cases degeneration only has been seen, 
and it is probable that slight swelling interferes with conduction. Facial 
neuritis differs from multiple neuritis in that alcoholism is a subordinate 
factor and the chief change is not in its peripheral twigs but in the trunk, 
usually within the Fallopian canal. 

Symptoms. — The symptoms sometimes begin with prodromes as 
vertigo, headache, tinnitus, pain or more often twitchings in the face, 
even fever or albuminuria, or sometimes without prodromes, in which 
cases one half of the face is rather suddenly paralyzed and becomes 
"completely immobile and toneless" within two days. The forehead is 
smooth, the lids cannot close (lagophthalmos), the tears run over the 
cheek, and when a strong effort is made to close the eyes, the eye on 
the affected side is turned upward by the inf. oblique muscle (Bell's 
sign). The orbicularis at times escapes involvement, since it receives 
some fibers from the third nerve. Smell is impaired because of absence 
of tears, the nasal aperture is smaller and cannot be dilated, sniffing on 
the affected side is impossible, and the nasolabial furrow is lost. The 
mouth is lower from paralysis of the levator anguli oris, it cannot be 
closed, and the saliva runs out, although its total secretion is often 
lessened (v.i.). Labial enunciation is imperfect, puckering the lips, as 
though for whistling, is impossible, and expectoration is impaired. The 
loss of wrinkles and expression on the affected side is more marked in 
adult and aged than in young subjects, especially about the eye, since 
years lessen the elasticity of the skin and the subcutaneous fat. Chew- 



1160 



DISEASES OF THE XERVOUS SYSTEM 



ing is impaired by weakness of the buccinator, and food accumulates 
between the teeth and the cheek. The unused half of the tongue be- 
comes furred. The tongue does not (but may seem to) deviate on 
protrusion on account of asymmetry of the mouth. The tongue is some- 
times slightly depressed from weakness of the stylohyoid and digastric 
muscles. The platysma paralysis is elicited by asking the patient to 
depress the lower lip. The palate is sometimes described as sagging, 
the speech as nasal, the uvula as deviating towards the sound side, but 
the uvula and palate are often asymmetrical in health and there is a 
growing tendency to regard the spinal accessory as the motor nerve 
for these structures (Gowers, Jackson). 

Taste is lost in disease of the nerve between the geniculate ganglion 
and the offset of the chorda; it is lost in half the cases of " exposure" 
neuritis; it is not impaired in disease of the pons or in disease outside 



Fig. 78. 

root facialis 



SUPER. MAJOR i 
PETROSAL 1 



OUSTICUS 
LATE GANGLION 



STYLO-MASTOID 
FORAMEN 



:PHENO-PALATINE 
GANGLION 




POSTERIOR AURICULAR 
NERVE 



DIAC-ASTRIC NERVE 
STYLOHYOID 



' Relations of the fifth and seventh nerves and branches of the seventh. 



the skull (see Diagram). The chorda supplies the anterior two-thirds 
of the tongue and the glossopharyngeal the posterior third. Perverted 
taste (parageusia) results from irritation of Jacobson's nerve or the 
tympanic plexus. Hearing may be impaired. Deafness and tinnitus 
result mostly from coincident disease of the ear. When the stapedius 
is paralyzed, the unopposed tensor tympani (which arises from the 
fifth nerve) overacts and results in aural oversensitiveness especially 
to low notes (Lucae), which is termed hyperakusis or oxyokoia. 

All facial reflexes are abolished. Wasting may be noticed in thin 
subjects, and the reaction of degeneration appears in a week or two in 
severe cases. In cases of moderate severity, the excitability may be 
first increased and then gradually decreased in seven to ten days. Sen- 
sation is usually normal, since the facial is an almost wholly motor 
nerve; pain, even ansesthesia in the ear and tenderness over the nerve 



DISEASES OF CRANIAL NERVES 1161 

trunk, are sometimes observed; they are caused either by involvement 
of the fifth nerve, or possibly because the facial nerve carries some 
sensory filaments. Accidental sympathetic symptoms, as oedema or 
sweating, have been observed. Herpes is rare and indicates trifacial 
involvement. The saliva is decreased (the fibers for its secretion run 
with the chorda) and secretion of tears is lessened (the fibers from the 
facial nerve run to the fifth by the large petrosal nerve). 

Diagnosis. — The diagnosis is made at a glance in fresh cases, while 
in older cases secondary spasm (v. i.) on the paralyzed side may at 
first cause confusion. The etiological diagnosis is important, as is also 
the topographical. 

1. Supranuclear paralysis, paralysis in the upper neurone, from the 
cortex to the nucleus, is differentiated as follows: 



Central or Supranuclear Peripheral (Nuclear and 

Palsy. Infranuclear) Palsy. 

Etiology; vascular disease, tumor, ab- Neuritis, ear disease, etc. 
scess. 

Distribution of paralysis: partial, lower Complete: orbicularis and occipito- 
facial involved or only slight or tran- frontalis involved. When eyes can- 
sient weakness of orbicularis palpebra- not be closed, probably peripheral or 
rum. nuclear. 

Reflexes persist and increased. Lost. Paralysis flaccid. 

Taste, auditory, salivary and sensory Often present, 
symptoms lacking. 

Pilocarpin increases salivary flow. Does not increase it. 

Voluntary motion lost, while emotional Both lost, 
movement very often persists. 

Degenerative reaction and wasting ab- Present, 
sent. 

Cerebral symptoms present, general as Absent, 
headache, vertigo, delirium, in- 
creased reflexes or focal as cortical 
epilepsy, hemiplegia, usually weak 
tongue, alternating paralysis (see crus 
and pons localization). 

In lesions of the pons, all parts of the facial nerve are affected, 
wherein it differs from facial nerve disease in the internal capsule. In 
nuclear disease, the orbicularis oris is less involved, or escapes affection, 
its centre being in the hypoglossus nucleus. 

2. Localization in the peripheral type (see Fig. 78) may be (a) in 
the pons (q. v.). General disease of the posterior pons also affects 
the sixth nerve about whose nucleus the seventh nerve curves, (b) 
In localization at the base, taste is not involved and deafness results 
from coincident disease of the eighth nerve, (c) It may be in the 
Fallopian canal, when taste is impaired, the salivary flow decreased, 



1162 DISEASES OF THE NERVOUS SYSTEM 

and hearing often abnormally acute, (d) It may be external to the 
skull and then there is no involvement of taste, salivary flow, or the 
stapedius. 

Double facial paralysis is rare and usually indicates disease within 
the skull. It may occur in bulbar paralysis, in disease of both sides of 
the pons, or one focus in its centre, in double otitis, especially syphilis, 
multiple neuritis, tetanus (of which J. H. Lloyd in 1905 collected 7 
cases), or in a form observed in childhood with ocular paralysis (q.v.). 
Hysterical facial paralysis is extremely infrequent; a case is reported 
in which organic facial paralysis existed on one side and an hysterical 
paralysis on the other. 

Course and Prognosis. — The onset is rapid and the disease is usually 
manifest during the first day. Its duration varies from a week to over 
a year, two or three months for moderate, and six to eight (eighteen) 
months for severe cases. Even in cases which have seemingly re- 
covered and in those lasting over a month, some slight vestige of 
paralysis usually remains. The prognosis depends (1) on the cause; it 
is favorable in syphilis, birth trauma, and polyneuritis; in ear disease 
it is better if the drum has not ruptured; it is unfavorable in tumor 
or nuclear disease; (2) it depends on the electrical reaction. If after 
ten days, the irritability is not reduced, the outlook is good and recovery 
may be expected in about three weeks; if after fourteen days it is 
lowered but not lost, recovery occurs within two months; if after 
fourteen days the irritability is lost, the prognosis is doubtful and the 
course is likely to cover months. Recurrence is infrequent, although 
five attacks are recorded. Contracture (secondary overaction) usually 
occurs in four to six months and progresses for eight to twelve months, 
when it lessens, and disappears in mild but remains to some extent 
in severe cases. In old subjects it balances up the facial contour; in 
young subjects it produces deformity. It is thought to depend on an 
altered functional state of the nucleus. 

Treatment. — (a) The cause should be reached, if possible; for 
example, antisyphilitic remedies and ear-drainage have cured cases 
even of twenty-three years' duration, (b) Antirheumatic drugs are 
inefficacious, and the salicylates do not usually shorten the course. 
A mercurial purge, hot fomentations, which must be carefully main- 
tained for two or three days, keeping the patient indoors, and the 
application (invariably) of a blister over the mastoid and one over the 
side of the neck are beneficial, (c) Correction of deformity is always 
necessary. The eye should be douched with boric acid, bandaged 
closed during sleep and the lids massaged, the cheek and mouth 
should be massaged upward, and the placing of a hook in the angle of 
the mouth (sustained by tape over the ear or by adhesive plaster) 
prevents deformity to some extent. At night the eye should be closed 
by a light compress, (d) Electricity should not be used for two or 
three weeks, and then the galvanic current should be given, for fifteen 
minutes each day, in strength just sufficient to produce muscular 
contraction; the application of the anode over the muscles is the least 



DISEASES OF CRANIAL NERVES 1163 

painful method. The faradic current causes pain, (e) For con- 
tracture little can be done, excepting massage and steaming the face. 
(/) In irreparable cases, surgical transplantation of the facial trunk 
to the spinal accessory nerve has been successfully performed. (Spiller 
thinks anastomosis with the hypoglossus produces better results.) 

Facial and Mimetic Spasm (Tic Convulsif). 

Etiology. — The causes are (a) organic disease in the cortex, pons 
or nerve trunk, which irritates (perhaps later paralyzes) the centre, 
nucleus or paths. Irritation of the fifth nerve is considered causal. 
(6) There is an idiopathic form, which occurs in persons between the 
fortieth and sixtieth years, most often in women with neuropathic or 
emotional tendencies (see Habit Spasm under Chorea). There is 
also a reflex form which results from worms or uterine disease. 

Symptoms. — The spasm begins paroxysmally on one side and is 
more often clonic than tonic. The clonic form affects the orbicularis 
palpebrarum (blepharospasm) and zygomatici most frequently, 
although the frontalis, chin depressors or all the facial muscles may be 
concerned in severe cases. Pain and paresis are absent save in pro- 
gressive organic disease. The spasm is lessened by rest, and is in- 
creased by cold or emotion. It is usualy unilateral, but may spread 
to the opposite side or exceptionally to the muscles of mastication, or 
those of the tongue, pharynx, larynx, neck or arm. The tonic form 
is seen in photophobic disease of the eye, in paralysis agitans, tetanus, 
tetany or hysteria. The prognosis is unfavorable after the first few 
months, and the disease is then likely to last for years or for the rest of 
the patient's life. 

Treatment. — Treatment is often useless, and varies with the cause 
of the affection. Trigeminal irritation should be removed if possible. 
Arsenic has proved beneficial in some cases, but nervines and anti- 
spasmodics are generally useless. Galvanization, especially if tender 
points are found, has cured a few cases (Berger). Wier Mitchell has 
recommended freezing of the cheek with ethyl chloride. Stretching of 
the facial nerve usually affords relief, which is but temporary, although 
a few cures are on record. 



The Eighth or Auditory Nerve.— The eighth nerve in the old 
nomenclature was called the portio mollis of the seventh pair, the 
facial nerve being the portio dura; as the names imply, the auditory 
is softer than the facial nerve and therefore less resistant to pressure. 
It is purely sensory and consists of two distinct roots, the cochlear and 
vestibular. At the point where their roots separate is found a group of 
cells, analogous to the spinal ganglia, from which arises Wrisberg's 
nerve, an accessory structure with vasomotor and salivary secreting 
fibers. 

The cochlear nerve is the true auditory nerve and its nuclei are found 
in the floor of the fourth ventricle. It is connected through the tee- 



1164 DISEASES OF THE XERVOUS SYSTEM 

mentum of the cms and internal capsule with the contralateral and to 
a less degree with the homolateral temporosphenoidal lobe. It is 
distributed to or arises from the cochlea and ganglionic cells of the 
organ of Corti. (a) Cortical disease (see Brain Localization) may in 
rare cases cause word deafness, as may (b) disease of the auditory 
tracts by lesions of the lateral lemniscus, the (post.) corp. quadrigemina, 
internal capsule or less often of the pons. Nuclear disease is almost 
unknown. Neuromata are rare, but occur on the auditory trunk 
oftener than on any other cranial nerve. The nerve trunk may degen- 
erate in tabes, (c) Lesions at the base may follow trauma and menin- 
geal inflammation, hemorrhage, or syphilis, (d) Most auditory nerve 
diseases result from disease of the internal ear, which is either primary, 
or secondary to disease of the middle ear; these affections include 
acute or chronic inflammation, syphilis, degeneration or hemorrhage 
in the labyrinth. There are three prominent symptoms: (a) Nervous 
deafness may result. Deaf -mutism is congenital in 80 per cent, and is 
acquired in early life in 20 per cent, of cases. Deafness from occlusion 
of the meatus or from disease of the middle ear is excluded by Rinne 's 
test ; a vibrating tuning-fork or watch, if held over the meatus, is not 
hea,rd in these affections, but is heard when its base is placed on the 
mastoid which conducts vibrations to the internal ear. In disease of 
the internal ear, bone-conduction is lacking. Differentiation between 
deafness due to disease of the internal ear and that due to bone disease 
is only made by means of the associated symptoms. The treatment of 
nervous deafness is etiological. Iodides are sometimes beneficial, as 
are full doses of pilocarpine. Electricity is nearly always useless. 
(b) Auditory hyperesthesia may result from central or peripheral 
disease. In genuine hyperesthesia (hyperacusis), sounds are heard 
by the patient which other individuals may not hear; this occurs in 
hysteria, epilepsy, migraine, meningitis, acute mania and at times 
after use of caffeine, alcohol or opium. The spurious hyperacusis 
results from paralysis of the stapedius. In dysesthesia (dysacusis) 
ordinary sounds cause disproportionate sensations or discomfort; 
this is common in headache and cerebral disorders, (c) Tinnitus 
aurium designates subjective distressing and intractable sensations, 
as ringing, roaring or whistling in the ears. In 80 per cent, of cases it 
is caused by disease of the internal ear. It may also occur in any 
disease of the middle ear, when there is cerumen or foreign bodies in 
the external meatus, or occlusion of the Eustachian tube, when the 
individual is subject to long exposure to loud sounds, as in boiler 
factories, and in the neuroses (hysteria, neurasthenia, migraine, 
epilepsy), aneurysm, anaemia, gout or cinchonism. Sounds of centric 
origin are usually continuous and sometimes elaborate. Wax or 
bilateral labyrinthine disease may also cause continuous tinnitus, 
while in anaemia or aneurysm, these sensations are intermittent 
(Gowers). Hearing may be hyperacute, deranged or lost. Spasm of 
the palate or musculature of the Eustachian tube may produce a most 
annoying snapping sound, which is at times audible to bystanders. 



DISEASES OF CRANIAL XERVES 1165 

While nothing is usually heard on examination, in children or less 
often in adults we may hear a systolic brain murmur (see Brain Tumor). 
Treatment depends on the cause. Bromides are most useful when 
combined with a few drops of the tr. belladonna or cannabis indica. 
Quinine was recommended by Charcot and Politzer and salicylates 
by Gowers, but they seldom give relief. Full doses of nitroglycerine 
relieve certain cases and counterirritation over the mastoid sometimes 
mitigates tinnitus. 

The vestibular nerve arises from the medulla, supplies the vestibule 
and semicircular canals, subserves sensation of space and equilibration, 
and has cerebral and cerebellar connections. 



Meniere's Disease, Auditory Vertigo, Vertigo ab aure l&sa. — -Paul 
Meniere in 1861 described a condition consisting of vertigo, tinnitus, 
vomiting and sometimes deafness, developing with apoplectiform 
suddenness, and due to acute labyrinthine disease. The lesion is 
usually a chronic, slightly irritative disease of the vestibular nerve, 
which supplies the organs of equilibration, the semicircular canals. 
According to Gowers 80 per cent, occurs in persons between the 
thirtieth and sixtieth year, 66 per cent, in males, and 90 per cent, of all 
cases of vertigo not due to epilepsy or organic brain disease are 
caused by lesions of the labyrinth. Frankl-Hochwart thus classifies 
Meniere's complex, which may be elaborated as follows: (a) Apo- 
plectiform cases, which occur in healthy ears, of which few more than 
30 cases are recorded, due to labyrinthine hemorrhage, or to trauma ; 
leukaemia and arteriosclerosis are promoting factors and it is thought 
that acute angioneurotic transudation of lymph may occur in the 
canals, (b) Cases developing in ears already acutely or chronically 
diseased; the internal ear is the usual seat of disease, but the external 
or middle ear may be affected, or the branches of the eighth nerve, 
perhaps by tumors, syphilis, tabes, paretic dementia, gout, cold, 
facial paralysis or drugs, such as quinine and the salicylates, (c) 
Cases caused by external influences or procedures, as pressure on the 
drum by violent douching of the ear; (d) pseudo- Meniere's disease, 
which occurs in the neuroses, as epilepsy, hysteria, neurasthenia 
migraine, or sea-sickness. 

Symptoms. — The symptoms begin gradually or with a sudden 
stroke, and are paroxysmal; the attacks may be separated by weeks 
or months or perhaps occur daily, (a) The vertigo is subjective or 
objective, perhaps combined; the patient cannot stand; he is likely 
to fall backward, or, if standing is possible, is ataxic. These symp- 
toms indicate lesion in the vestibular nerve; there is occasionally 
momentary loss of consciousness; some slight vertigo may persist 
between paroxysms, (b) Nausea and vomiting are usual, save in the 
lighter forms, and are often attended by headache, sometimes collapse, 
pallor and clammy skin, and rarely by death, (c) The tinnitus of a 
roaring, throbbing character and (d) nervous deafness, which is usually 



1166 DISEASES OF THE XERYOUS SYSTEM 

not absolute, indicate disease of the cochlear nerve. Nystagmus, 
double vision and ataxia are occasional symptoms, and result from 
the relations between the labyrinth, cerebellum and cerebrum. The 
prognosis is always uncertain. Acute or progressive disease is un- 
favorable. The vertigo may cease when complete destruction of the 
nerve results in deafness. Some cases recover. 

Diagnosis. — Aural vertigo constitutes 90 percent, of vertigo. Differ- 
entiation is as follows : (a) Gastric disease may cause vomiting or vertigo 
(a stomacho lasso, Trousseau) but does not produce tinnitus nor deaf- 
ness. Gastric vertigo was once thought to cause 80 per cent, of cases 
of vertigo; now, but o per cent. (Gowers) is attributed to it. Many 
of these cases are neurotic, (b) Epilepsy, especially petit mal, may 
produce vertigo, very rarely tinnitus or deafness, and much oftener loss 
of consciousness, (c) Cardiac disease, as aortic regurgitation or 
arteriosclerosis, may cause vertigo but not the other symptoms, (d) 
Organic brain affectio?is, as tumor, have other distinctive signs, as 
headache, or focal lesions. Confusion is possible with arteriosclerotic 
vertigo, and especially with coincident accidental deafness. (e) 
Ocular vertigo ceases on closing the eyes. Gerlier (1887) described a 
form which is endemic in France and Switzerland, and is characterized 
by vertigo, great depression, paretic weakness of the neck and limbs, 
ptosis, strabismus, diplopia and retinal hyperemia, hemorrhage or 
oedema. A similar form occurs in Japan. Recovery occurs in one to 
four months. 

Treatment. — Labyrinthine disease is little influenced by drugs, 
except when syphilis and gout are its causes. Quinine, salicylates and 
nitroglycerine should be given (see Tinnitus). Bromides are most 
useful in daily doses of one dram. Galvanization with the anode 
over the ear and cathode to the neck has seemingly helped some cases, 
as has blistering of the mastoid. Disease of the pharynx, Eustachian 
tube, and accumulation of wax must be recognized and treated. 
Removal of the malleus and incus with mobilization of the stapes 
relieves a few cases. 



Ninth or Glossopharyngeal Nerve.— This nerve is almost inseparably 
connected in its course and functions with the vagus and the internal 
part of the spinal accessory nerve; their nuclei blend, their sensory 
and motor filaments supply the digestive tract from the spinal accessory 
nerve, and send motor branches to the lungs, larynx and heart. Com- 
pared with disease of the first eight cranial nerves, affections of these 
visceral nerves are infrequent. Of all the cranial nerves, the ninth is 
least understood and is almost never the seat of isolated disease. . The 
causes of its disease are essentially the same as those of the vagus (v. i.) ; 
its nuclei suffer in bulbar palsy and its roots in basal disease. 

It is distributed as follows: (a) its sensory fibers supply the back 
of the tongue, pharynx, soft palate, tonsil, upper pharynx, Eustachian 
tube and tympanic cavity. It is probably the nerve of nausea. (6) 



DISEASES OF CRAXIAL XERVES 1167 

Its motor fibers supply the upper pharynx and possibly the palate. 
(c) Taste fibers are usually thought to be distributed to the posterior 
third of the tongue and palate, but they are not found in the nerve 
root and are considered to pass through the fifth nerve to the brain. 
Increased flow of saliva and loss of taste on the root of the tongue may 
result from disease of the middle ear due to relations between the nerve 
of Jacobson (ninth) and the branches of the fifth nerve. The nerve 
is thought to regulate and inhibit the contractions of the pharynx, 
which become frequent (spasm) in disease or on section of the nerve. 



Tenth Nerve or Vagus. — This nerve arises in the medulla above the 
ninth, below the eleventh, and outside of the twelfth nuclei. With 
the internal part of the accessory nerve it has an enormously diffuse 
and important visceral distribution. It is a mixed nerve, the motor 
fibers originating from the nuclei, and the sensory fibers from the 
jugular and plexiform ganglia. It is generally maintained that the 
vagus carries the sensory and the accessory, motor fibers. 

Etiology. — Affections of the vagus result from: (a) Nuclear disease, 
as degenerative bulbar palsy or acute vascular lesions, which usually 
also involve other nuclei; (b) involvement of the root and trunk by 
meningitis, syphilis, caries, trauma, tumor, aneurysm of the arch or 
its branches, carcinoma, oesophageal growths, tuberculous or other 
adenopathies, pleural (right-sided especially) or pericardial effusions 
or adhesions, mediastinitis, goitres, operations on the neck (laryngeal 
paralysis occurs in 14 per cent, of thyroid extirpations) or rarely 
neuroma and neuritis from diphtheria or other infections, tabes, or 
plumbism. Cortical, especially functional, causes may occasion symp- 
toms. Irritative and paralytic manifestations occur in numerous 
combinations and will be treated topographically. 

Pharyngeal Branches. — The pharyngeal plexus consists of bran- 
ches from the ninth and tenth nerves. In paralysis, sensation and 
the pharyngeal reflex are lost, while bilateral (rarely unilateral) disease 
causes dysphagia. The stomach tube can be introduced without 
sensation or spasm. Pulpy foods are better swallowed than dry foods 
or fluids. Food is likely to enter the larynx, and when the palate is 
involved there is regurgitation into the nose, and nasal speech results. 
The innervation of the palate is not definitely known, but it is probably 
supplied by the accessory nerve. Spasm is not frequent, is always 
functional, is transient or recurrent, does not allow of introduction of 
the stomach tube, and includes the globus hystericus, oesophagismus, 
pharyngismus, false and genuine hydrophobia and the pharyngeal 
crises of tabes. The oesophagus is rarely affected except in diseases of 
the centres or trunk. 

Laryngeal Branches. — There are two laryngeal nerves, the supe- 
rior laryngeal and the recurrent laryngeal. 

The superior laryngeal is (a) the sensory nerve for all parts above 
the vocal cords, (b) the motor nerve for but one larynx muscle, the 



1168 



DISEASES OF THE NERVOUS SYSTEM 



cricothyroid, which modulates the voice by regulating tension in the 
cords, and (c) it is the motor nerve for the depressors of the epiglottis, 
the thyro-epiglottic and ary-epiglottic muscles, paralysis of which causes 
the epiglottis to stand upright, thereby risking entrance of food into the 
larynx and aspiration pneumonia. (Some maintain that the recurrent 
nerve supplies these depressors.) 

Figures illustrating the laryngeal paralyses, from Church's Nervous 
Diseases. 



Fig. 79. 













1, normal phonation ; 2, normal deep inspiration; 3, normal cadaveric position; A, bilateral ad- 
ductor palsy; attempted pnonation; B; Left adduction palsy; attempted phonation; C, 
bilateral abductor paralysis; deep inspiration; D, left abductor paralysis; deep inspiration; 
affected cord in cadaveric position; E, left abductor paralysis; phonation; affected cord in 
cadaveric position; right cord crossing medium line; F, bilateral thyro-arytenoid paralysis; G, 
bilateral thyro- arytenoid paralysis and paralysis of arytenoideus, giving an hour-glass opening. 



DISEASES OF CRANIAL NERVES 1169 

The recurrent laryngeal curves around the aortic arch on the left and 
the subclavian artery on the right side; (a) it is the sensory nerve to 
the mucosa of the larynx below the cords and to the trachea and (6) 
is the motor nerve to every intrinsic muscle of the larynx except the 
cricothyroid. The larynx muscles are physiologically complicated, 
but they have three main movements: (a) to render the cords tense 
(this is accomplished by the cricothyroids and to a less extent by the 
thyroarytenoids) ; (b) to adduct the cords, which is done chiefly by 
the lateral crico-arytenoids (also by the thyro-arytenoids and arytenoids) ; 
(c) to abduct the cords, which is done by the post, crico-arytenoid; 
it is especially important because it is the only special abductor; it is 
very frequently and almost invariably first involved in incomplete 
recurrent paralysis (Rosenbach and Semon), even though the ad- 
ductors are affected later in complete paralysis. 

Treatment depends wholly on the cause, which is usually peripheral. 
In nuclear types there is no therapy. Suggestion, or its equivalent, 
electrotherapy, is valuable in hysterical forms. The faradic current 
may be used, with the positive pole to the forehead and the negative 
to the larynx externally or internally; should this fail, the galvanic 
current may be given. Other measures include laryngeal gymnastics, 
in which the patient repeatedly attempts to speak, intralaryngeal 
insufflations of alum, other topical applications, the administration of 
strychnia hypodermatically, and Ollivier's procedure, in which the 
thyroid cartilage is compressed between the index-finger and thumb 
during inspiration and expiration, while the subject attempts to 
phonate. Tracheotomy and feeding by the nasal catheter are some- 
times indicated. 

Anaesthesia of the larynx is rare but may occur uni- or bilaterally 
in disease of the sup. laryngeal nerve, the vagus roots, its nucleus or 
in the hemianesthesia of hysteria or organic brain disease. In nuclear 
disease it is partial; in affections of the nucleus, root and trunk 
the reflexes are lost, but they are present in supranuclear and functional 
affections. Hyperesthesia is even rarer, being observed in neurotics 
as a tickling, tendency to cough or spasm; neuralgia and crises also 
occur. 

The most common form of laryngeal spasm is spasm of the adductors 
(which are especially concerned in reflexes inimical to entrance of foreign 
bodies into the larynx); it may result from centric, local (laryngitis 
with croup-like cough at night) or reflex irritation from distant or 
neighboring foci as elongated uvula, goitre or hypertrophy of the 
pharyngeal tonsil. It includes laryngismus stridulus, which occurs in 
children under three years of age, especially in boys, and was previously 
referred to the thymus gland, but is due to rickets in 66 per cent, of 
cases and also to tetany, and reflexly to alimentary disorders ; it comes 
on at night or on awakening in the morning, with croup-like cough, 
and presents all the symptoms of acute suffocation, as inspiratory 
and expiratory stridor, pallor, cyanosis, wide pupils, protruding eyes. 
low diaphragm, involuntary evacuations, centric vasomotor and 

74 



1170 



DISEASES OF THE XERYOUS SYSTEM 



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DISEASES OF CRANIAL NERVES 1171 

cardiac disturbance and convulsions either generalized or of the 
infantile carpopedal type. The attacks last from a few seconds to 
one-half or one minute and are sometimes attributed to loss of temper 
when they follow a reproof. In the adult, laryngeal spasm occurs in 
tabes, hysteria, tetany, hydrophobia, epilepsy (the initial cry of which 
arises from spasm), asthma or migraine. The attacks are recognized 
by the negative laryngoscopic findings, paroxysmal occurrence, and 
the stridor being manifest in both inspiration and expiration. Partial 
spasm occurs in some types of stuttering, in clergymen's sore throat, 
and in explosive, unmodulated speech. 

Nervous cough is present in the explosive hysterical type, in the 
metallic ovarian form in young girls, and in the barking variety in 
young masturbators. 

Treatment of spasm includes removal of the cause, relief of local 
irritation, as affections of the ear (which has branches from the vagus) 
or pharynx, correction of hygiene, administration of tonics, as cod- 
liver oil in children, and such immediate measures as thrusting a finger 
into the throat, dashing water in the face, hydrotherapy, and for the 
attack chloral and bromides by enema, local application of cocaine, 
inhalation of chloroform and in adults nitrite of amyl and morphine. 

Pulmonary Branches. — The vagus and the sympathetic nerve 
form the pulmonary plexus. Afferent fibers convey sensory impres- 
sion to the respiratory centre; these include accelerating fibers which 
predominate, and inhibitory fibers, stimulation of which (sup. laryn- 
geal nerve) arrests breathing. Afferent impulses are also carried to 
the vasomotor centre. Efferent motor impulses are conveyed to the 
bronchi. Division of the vagus causes rapid congestion of the lungs 
with hemorrhage (also observed in acute lesion of the pons) and 
slower but deeper breathing; stimulation of the divided end of the 
nerve accelerates breathing even to its tetanic arrest. Broncho- 
pneumonic foci are as yet thought to be trophic but should be con- 
sidered aspiration pneumonia from paralysis of the palate and larynx. 
The pulmonary twigs are probably concerned in Cheyne-Stokes 
breathing, bronchial asthma and hiccough. 

Cardiac Branches. — The vagus and sympathetic nerves constitute 
the cardiac plexus, (a) Motor fibers from the spinal accessory nerve 
inhibit and coordinate cardiac action, which is sometimes under the 
control of the will; the heart may at times be slowed by pressure on 
the neck; marked irritation of the vagus slows the heart (bradycardia) 
or even arrests its action. Division may cause sudden death, though 
this is unusual in unilateral lesions. Paralysis of these fibers allows 
the sympathetic accelerator fibers to dominate, producing arrhythmia 
and tachycardia. Digitalis is naturally ineffective in paralysis of the 
vagus, (b) The sensory fibers are concerned in pain and palpitation 
(see Cardiac Neuroses), (c) These are probably trophic fibers, as 
Eichhorst's experiments show fatty myocardial degeneration on divi- 
sion of the vagi. 



1172 DISEASES OF THE NERVOUS SYSTEM 

Gastric Branches. — (a) Motor branches supply part of the stomach 
and are concerned in reflex vomiting; they cause nausea and are con- 
cerned in direct or centric vomiting, as in brain lesions, wherein the 
vomiting usually occurs without nausea. (6) There are sensory 
branches; the vagus is seemingly the nerve of hunger and thirst, and 
its disease often but not always causes anorexia and loss of thirst. 
Centric disease causes the gastric crises of tabes, and cortical func- 
tional disease produces the epigastric aura of epilepsy and perhaps 
gastralgia in the neuroses. Vertigo probably causes vomiting through 
the vagus. Intestinal and splenic symptoms are lacking in affections 
of the vagus, although the nerve somewhat accelerates peristalsis. 



Eleventh or Spinal Accessory Nerve (external portion). — The 
internal and minor part runs with the vagus, while the external and 
major segment is really a spinal motor nerve, arising from the lateral 
portion and ant. horns of the cord between the sixth cervical segment 
and the medulla. It courses upward through the foramen magnum 
into the cranium and leaves it with some of the true cranial nerves. 
It is the chief or sole supply of the sternomastoid muscles and the upper 
part of the trapezius, the lower two parts of which are supplied by 
the cervical and upper dorsal nerves. Rarely the eleventh supplies 
the whole trapezius muscle. 

Paralysis is rarely caused by cortical disease, because the muscles 
have bilateral representation. The usual causes are bulbar paralysis, 
lesions near the foramen magnum, meningitis (then usually with 
involvement of the inner accessory branches and the twelfth nerve), 
syphilis, trauma, disease of the cord (tabes, syringomyelia, progressive 
muscular atrophy), of the spine (caries, tumor), or disease of the nerve 
trunks, as cold, trauma or neuritis. The symptoms are paralysis 
of (a) the sternomastoid, in which there is impaired rotation of the 
face to the side opposite the lesion; in old cases contracture turns the 
face toward the paralyzed side, (b) That part of the trapezius from 
the occiput to the acromion is paralyzed, showing a concave instead of 
a straight line, which is best seen in deep inspiration or on shrugging 
the shoulders. (Paralysis of the second portion causes imperfect 
elevation of the arm, some drooping and winging out of the scapula, 
the lower part of which is drawn toward the spine by the rhomboids 
and lev. anguli scapulae; paralysis of the third portion results in weak- 
ness in the adduction of the scapula to the spine.) If it is bilateral 
as in chronic meningitis of childhood or progressive muscular atrophy, 
the head falls forward or backward as the sternomastoids or trapezii, 
respectively, are affected. In peripheral disease there is wasting and 
the reaction of degeneration. In centric disease the electrical reactions 
vary, as in progressive muscular atrophy. 

Accessory Spasm, Spasmodic Torticollis or Wryneck.— Etiology. — 
It occurs in women in 66 per cent, of cases (Gowers), although Osier 
finds it largely in males, between 30 and 50 years of age. A neurotic 



DISEASES OF CRANIAL NERVES 1173 

tendency, bad health, trauma, overexertion, acute infections, alco- 
holism, plumbism, cervical caries, brain tumor, and diseases of the 
eve and ear (torticollis ab oculo lseso, ab aure lsesa) are among its 
uncertain causes. 

Symptoms. — -The symptoms vary as the affection is clonic or tonic, 
unilateral or bilateral, and also with the number of muscles involved. 
One sternomastoid is generally involved, especially in tonic spasm, 
in which the occiput is turned to the diseased side, the face to the oppo- 
site side and somewhat upward, and the ear brought nearer the clavicle. 
The upper part of the trapezius comes next in frequency of involve- 
ment, and is affected equally by clonic and tonic spasm. The affected 
shoulder is raised and slightly rotated, the scapula drawn toward the 
spine and the head backward. The spine is often convex toward the 
diseased side. The splenius is half as frequently affected (Gowers), 
the head being drawn backward, the face a little to the affected side 
and upward. Less often the scalenus, platysma, rectus and obliquus 
capitis are affected. The muscles in tonic spasm are hard, prominent 
and sometimes hypertrophied. Clonic spasm disappears during 
sleep, but is increased by fatigue and emotions; it may also invade the 
face, neck, eyeballs, vocal cords or the arm. There may be pain, 
fatigue and rarely tender spots or formication from compression of the 
brachial plexus by the scaleni. Bilateral clonic or tonic spasm of 
the trapezius draws the head backward (retrocollic spasm), and 
always involves the frontalis muscle. 

Course and Prognosis. — The onset is gradual, the disease is usually 
stationary or progressive in its course, rarely recurrent; recovery is 
infrequent. The outlook is generally grave in well developed types. 

Diagnosis. — (a) In congenital or fixed wryneck there is no active 
spasm. One sternomastoid (but rarely the trapezius) shows atrophy, 
induration and cicatrization, which Stromeyer considers due to traction 
on the neck with injury during delivery. Seventy per cent, of cases 
occur in left occipito-anterior presentations. The disease escapes 
notice for years, because of the shortness of the child's neck. Wilks 
always found facial asymmetry. Golding-Bird considers the affection 
a contracture from a central lesion. Tenotomy cures it. (b) Hyster- 
ical torticollis occurs in subjects under thirty years of age; other stigmata 
usually develop. Bompaire and Brissaud describe a mental torti- 
collis, which is clearly a cortical or psychical phenomenon, (c) Tor- 
ticollis may occur in children from dentition to puberty; clonic spasms, 
especially in the deep muscles, lead to nodding, salaam movements, 
spasmus nutans, nictitatio spastica. The eyes may show nystagmus. 
The affection may develop from reflex dental or digestive disorders, 
or from organic cerebral disease. It is sometimes habit spasm, 
hysteria, or even part of an epilepsy or idiocy. 

Treatment. — Treatment is first etiological. Nervines, sedatives 
and electricity seldom produce permanent results. Morphine is 
a dangerous agent, although its local hypodermatic use has led to 
recovery. Massage and deep compression are occasionally helpful. 



1174 DISEASES OF THE NERVOUS SYSTEM 

In chronic cases resection of the accessory nerve is indicated. If 
many muscles are involved, the third and fourth cervical nerves must 
also be resected. Successful results are reported by W. W. Keen and 
Noble Smith. 



Twelfth or Hypoglossal Nerve. — This is purely a motor nerve. 
Paralysis of the tongue is (a) rarely cortical; supranuclear glossoplegia 
from lesions between its centre in the lower part of the ant. ascending 
and the third frontal convolutions, almost always occurs with hemi- 
plegia and paralysis of the lower facial fibers; there is no wasting or 
reaction of degeneration. The root of the tongue is higher (hyoglossus 
paralysis) and on protrusion the tongue deviates to the paralyzed side, 
being pushed over by the sound genioglossus. (b) Nuclear paralysis 
occurs often in degenerative disease as bulbar paralysis, sometimes in 
tabes or paretic dementia, and much less frequently in acute inflam- 
mation or softening in the medulla. Nuclear lesions are almost 
invariably bilateral (since the nuclei are closely contiguous), and show 
the reaction of degeneration and wasting, the mucosa being wrinkled 
over the atrophic half. Wasting may be more marked than paralysis. 
Fibrillation is frequent, as in paretic dementia, from cortical and nuclear 
changes. In bilateral glossoplegia the tongue cannot be protruded, 
there is impairment of the first act of swallowing, in chewing and 
articulation, all of which are but slightly marked in unilateral paralysis, 
(c) Infranuclear paralysis results from lesions near the surface of 
the medulla, which may produce unilateral paralysis of the tongue, 
palate and vocal cord. Contralateral hemiplegia may occur. The 
lesion may affect one or both nerves. Syphilis, trauma or tumors 
are causal; neuritis is infrequent (there being recorded only 40 cases 
of peripheral, isolated hypoglossal paralysis, Panski, 1903). Wasting, 
the degenerative reaction and fibrillation are present. Treatment is 
that of other paralyses. 

Spasm is rare either in the tonic or clonic form. It occurs in chorea, 
facial spasm, certain types of stuttering, epilepsy (in which the tongue, 
protruded by the genioglossus, is bitten), hysteria (in which the tongue 
is rarely bitten), certain psychoses, meningitis, neurotic spasm in 
speakers (aphthongia) or musicians. The prognosis varies with the 
cause and in general is favorable. 



5. Diseases of the Spinal Nerves. — The spinal nerves differ from 
the cerebral in that they contain sensory, motor and vasomotor fibers 
Disease or injury therefore suspends motility and sensation, causes 
vasomotor paralysis, trophic changes or wasting, glossy skin, the 
reaction of degeneration, atrophy and contracture. 

Phrenic Nerve. — Paralysis. — (a) Disease, or trauma of the vertebrae, 
cord, membranes or of the third, fourth and fifth cervical nerves of 



DISEASES OF SPINAL NERVES 1175 

origin may cause it. In disease of the cord other paralysis is always 
present; phrenic paralysis is usually bilateral, (b) Its trunk is well 
protected but may be injured in its course or damaged by aneurysm, 
tumors, or pleurisy. Neuritis is a rare cause, although it is sometimes 
involved in multiple neuritis or degenerative lesions as tabes or pro- 
gressive muscular atrophy. 

Symptoms. — The diaphragm is paralyzed on one or both sides. 
The abdomen retracts in inspiration and bulges in expiration, which is 
the converse of its normal movements. Litten's diaphragmatic sign 
is naturally absent, and there is no inspiratory descent of the liver or 
spleen. Blowing, coughing and pressing at stool are impossible. Costal 
breathing is exaggerated, the accessory muscles are strongly in play, 
dyspnoea and cyanosis are present especially on exertion, and coincident 
bronchitis may cause most alarming symptoms, allowing stagnation 
of mucus and basal congestion. The nerve may be tender in the neck. 

Diagnosis and Treatment. — Costal hysterical breathing may at first 
cause confusion, as may inflammation and degeneration of the dia- 
phragm from diaphragmatic pleurisy. The outlook is always grave. 
It is more favorable in syphilis, lead or diphtheritic neuritis than in 
alcoholic forms. Treatment is that of the cause, but is usually futile. 
Faradic phrenic stimulation is sometimes beneficial, as in apparently 
asphyxiated new-born infants. 

Phrenic Spasm. — 1. Clonic spasm, singultus, or hiccup is a form 
in which the diaphragm spasmodically contracts with a sound due to 
sudden closure of the glottis, sometimes 50 to 100 times a minute. It 
is probable that the vagus and respiratory centres are involved, for 
dyspnoea, dysphagia or dysarthria may occur. Clonic spasm occurs 
(a) in inflammation, either thoracic (pleurisy, pericarditis) or abdom- 
inal (peritonitis, appendicitis, obstruction); (b) in irritation; oesopha- 
geal, mediastinal, hepatic or gastric, directly or reflexly; (c) in 
nervous affections, as centric disease or the neuroses; and (d) in 
toxaemia, fevers or uraemia. Treatment is that of the cause. Gastric 
lavage; apomorphine; circular constriction of the lower chest with 
the head bent forward; attempts to sneeze, cough, breathe deeply or 
press down with the glottis closed; faradization, freezing, blistering 
the neck and epigastrium; antispasmodics and depressomotors, as 
asafcetida, chloral, or bromides; and narcotics, and inhalations of 
chloroform or amyl nitrite may be beneficial, although the affection is 
often intractable. 

2. Tonic phrenic spasm is rarer. The causes are tetany, epilepsy, 
tetanus, rheumatism, and hysteria. The diagnosis is easy. The lower 
chest and upper abdomen are distended and often sensitive, the upper 
chest moves rapidly and forcibly, with the accessory muscles in full 
play, there is no respiratory excursion, the lungs are acutely distended, 
the abdominal viscera are luxated downward, there is dyspnoea, and 
cyanosis and death may result. Treatment consists of the application 
of heat, blisters and the faradic current to the lower chest, and the 
use of chloroform inhalations and morphia internally. Analogous 



1176 DISEASES OF THE NERVOUS SYSTEM 

spasm may occur in the respiratory muscles, as yawning, sneezing, 
coughing, laughing and weeping spasms, possibly from vagus disease, 
or from the neuroses, psychoses, multiple sclerosis, bulbar paralysis 
or disease of the ear, nose or stomach. 

The Posterior Thoracic Nerve. — This nerve is often affected in its 
long course, from trauma, muscular strains in overhead work (the 
nerve originates in the scalenus medius) and from carrying loads on 
the shoulder — whence its occurrence in 90 per cent, of cases in men; 
it is also involved in muscular atrophies with other muscles and in 
neuritis. The results are impaired fixation of the scapula, movement 
of the arm, and inspiration. The scapula wings out when the arm is 
moved forward, and stands less obliquely than normal, its outer part 
moving forward, while the lower angle is drawn in by the rhomboids 
and trapezius. The sole sensory change is pain in the neck and 
shoulder. The course is at best tedious, and rest, especially of the 
scaleni, is the prime indication. 

Suprascapular Nerve. — It originates in the fourth, fifth and sixth 
cervical nerves, and is affected in disease of the plexus or alone in 
trauma, shoulder dislocations, or falls on the hands. The supra- 
spinatus and infraspinatus are paralyzed, giving some weakness in 
fixation of the humerus, as uncertainty in writing, turning of the lower 
scapular angle up and in, some anaesthesia over the scapula, frequently 
shoulder girdle pain, and often involving the Circumflex Nerve, 
which arises from the fifth, sixth and seventh cervical nerves of the 
posterior cord of the brachial plexus. Deltoid paralysis (dislocation, 
crutch paralysis, plexus disease) produces inability to deviate laterally 
the arm, changes in the shape of the shoulder, which becomes angular, 
sometimes adhesions in the joint, which are probably trophic from 
its articular branch, and anaesthesia over the lower part of the deltoid. 
It may be confused with primary joint disease, in which, however, the 
scapula follows the arm movements. Paralysis of the teres minor is 
unimportant. 

Musculospiral Nerve. — Arising from all the roots in the plexus 
except the first dorsal, and curving around the humerus, it is the most 
exposed and most frequently injured nerve in the arm or body; injuries 
result from fracture, callus, blows, muscular exertion, carrying heavy 
weights, tying the arms to the side or behind the back, sleeping with 
the arm over the back of a chair, especially in alcoholics, lifting the 
arms during surgical anaesthesia, and Esmarch's constrictor; less 
often injury results from injections of ether, from cold or from lead 
palsy. Musculospiral (radial) paralysis involves (a) the extensors 
of the upper extremity, i. e., the triceps, so that the elbow cannot be 
extended, and the supinators; the triceps sometimes escapes affection; 
the supinator longus is not involved in lead palsy or traumatism 
below the lower third of the humerus and in centric disease it escapes 
because its centre is with the flexors. The extensors of the wrist are 



DISEASES OF SPIXAL NERVES 1177 

involved, producing marked atrophy of the back of the forearm and 
the characteristic wrist drop; the extensors of the thumb and fingers, 
are affected, and become semiflexed and can only be extended by the 
interossei (ulnar nerve) after the first phalanges are passively extended. 
Changes in the synovial sac or bones of the dorsal wrist produce the 
painless carpal tumor of Gubler, from involvement of branches to 
the wrist, or more probably from the mere mechanical action of flexion 
(see Lead Intoxication) . (b) Sensory disturbance, which is slight com- 
pared with the palsy, may rarely cause anaesthesia over the deltoid 
and over the back of the forearm or more often over the radial side of 
the dorsum of the hand, thumb, index and half of the middle finger. 
Most cases recover with rest and immobilization. Flexor contracture 
can be avoided by careful splinting. 

Median Nerve. — The median nerve originates from the outer and 
inner cords of the plexus and contains fibers from all its cervical 
roots. Isolated paralysis is not common. It results from trauma, 
fractures, stabs, carrying weights in the bend of the elbow, and sleep- 
ing on the arm. (a) Motor symptoms are conspicuous. Both prona- 
tors are involved, besides all the flexors of the forearm, wrist and 
fingers except the flexor carpi ulnaris and the ulnar part of the deep 
flexor of the third and fourth fingers. In the hand, the palmaris 
longus, the abductor, opponens and short flexor of the thumb (resulting 
in flattening of the thenar prominence and the "ape hand" from the 
index finger and thumb lying parallel) and the two radial lumbricales 
are affected. The second phalanges cannot be flexed on the first 
(save in the two ulnar fingers); flexion of the first phalanges by the 
interossei is possible; metacarpophalangeal subluxation may result 
from the unopposed extensor action of the interossei on the second 
and third phalanges. The paralyzed muscles may waste and trophic 
manifestations are quite common, (b) Sensory symptoms are often 
slight. Anaesthesia, if present, is greatest in the palm, front of the 
thumb, the first two fingers and half of the third. 

Ulnar Nerve. — Its origin is the last cervical and first dorsal nerves; 
its superficial course at the inner condyle, forearm and wrist, expose 
it to injury, as by dislocation of the elbow, cuts and pressure on the 
elbow during sleep and work. Neuritis occasionally causes paralysis. 
It must be distinguished from spinal disease, which ascends from the 
dorsal to the cervical region; this form is usually bilateral, and is 
preceded by ulnar anaesthesia (Biernacki) in tabes and paretic demen- 
tia. The flexor carpi ulnaris is paralyzed (the hand deviates to the 
radial side in attempts at flexion), and also the ulnar half of the deep 
flexors of the fingers, the muscles of the little finger, palmaris brevis, 
the interossei, the third and fourth lumbricals, the adductor and 
inner head of the short flexor of the thumb (the thumb being rotated 
toward the palm). The first phalanges cannot be flexed nor the others 
extended, although this is less in the first and second fingers, in which 



1178 DISEASES OF THE XERVOUS SYSTEM 

the lumbricals are supplied by the median nerve. The "claw hand" 
results, although it is less marked than in spinal muscular atrophy; 
the hypothenar eminence, palm and interosseous spaces become thin. 
Sensory loss is limited to the back and front of the ulnar side of the 
hand, the dorsum of two and a half fingers, and the front of one and 
a half fingers on the ulnar side. 

Combined Paralysis of the Arm Nerves. — This affection, described 
by Erb (1884), is very common and is due to affections of the verte- 
brae, cord or the nerve roots, to tumors, trauma or cicatrices of the 
neck, and wrenches or forcible delivery in obstetrics. Several nerves 
are involved, as the musculospiral and ulnar in fracture of the hu- 
merus, or in subcoracoid luxation; in Erb's case, the circumflex, 
suprascapular and musculocutaneous nerves, fifth and sixth cervical 
roots, with some branches from the fourth were imbedded in a cicatrix 
and paralyses of the deltoid, teres minor, spinati, biceps, brachialis 
and supinators, with few sensory signs resulted. Excision of the scar, 
resection and suture of the nerve resulted in recovery. Erb found one 
spot between the scaleni where all these nerves could be stimulated 
and where, therefore, they could be simultaneously affected. Neuritis 
ascending from the median nerve may cause ulnar and musculo- 
cutaneous or other paralysis. Obstetrical paralysis usually results in 
recovery, while adult forms depending on their etiology are often 
protracted or permanent. Flaubert (1827) described a combined 
paralysis, which usually bears Klumpke's (1885) name, in which 
paralysis of the first dorsal and eighth cervical roots (ulnar and median 
paralysis) also causes sympathetic symptoms, as narrowing of the 
pupil and the interpalpebral fissure. 

Brachial Neuritis. — This affection was first clearly described by 
Gowers and held to be a perineuritis of the plexus or nerve roots 
(radicular neuritis), occurring largely in gouty or rheumatic subjects 
over fifty years of age, but at times due to compression or trauma. 
The author saw one case which occurred in the right arm of a busy 
surgeon. A cervical rib may cause compression symptoms ; Reisman 
(1904) collected 46 cases of which 24 were operated on with good 
results. It is marked by great pain, the first, most severe and most 
enduring symptom. It is constant, with paroxysmal exacerbations,, 
is increased by the least movement, and is experienced over the plexus, 
nerves, or referred to the wrist or scapula. Associated with it are 
tenderness over the trunks or plexus, hyperesthesia of the skin, some 
muscular wasting, mostly in radicular forms, and somewhat less often 
anaesthesia, anaesthesia dolorosa, oedema, glossy skin and trophic 
alterations in the joints. Neuralgia, angina pectoris and aneurysm 
may cause diagnostic difficulties. Remak holds that reported recover- 
ies of acute poliomyelitis in children (Kennedy's temporary paralysis) 
are only plexus neuritis. The outlook is usually favorable, but a long 
course of from a month to more than a year, relapses and even in- 



DISEASES OF SPINAL NERVES 1179 

complete recovery (some wasting, cramps, rheumatic pains and joint 
adhesions) must be considered in framing the prognosis, despite 
perhaps early and careful treatment as in reduction of shoulder dis- 
locations. Treatment as in neuritis, consists of rest by immobilization, 
injection of cocaine in severe cases, and treatment of the underlying 
trauma, gout or rheumatism. 

Nerves of the Trunk. — These are rarely involved except in lesions 
of the spine or cord. The neuritic pain in Pott's disease or cord tumor, 
and the girdle pain of tabes are of great localizing value. It has been 
shown that herpes zoster is due to inflammation in the spinal root 
ganglia (Campbell and Head). 

Nerves of the Lower Extremities. — These nerves, except in sciatica, 
are less frequently affected than those of the arm. 

The Lumbar Plexus. — The lumbar plexus (the first three and a half 
lumbar roots) may suffer in abdominal tumors, glandular enlargements, 
parturition, psoas abscess, pelvic inflammations, spinal meningitis, 
vertebral disease or in neuritis ascendens. The symptoms are paralysis 
of the cremasters, flexors and adductors of the hip and extensors of the 
knee; all the hip flexors are involved in plexus disease only; great 
pain in neuritic forms is noted in the ilio-inguinal, iliohypogastric and 
genitocrural areas. Anaesthesia exists over the lower abdomen, front 
and sides of thigh and inner side of leg and foot and adjacent sides of 
first and second toes. 

Anterior Crural Nerve. — Lesions in the abdomen cause paralysis of 
the iliacus (not the psoas), the hip flexors and knee extensors, with 
wasting, loss of knee jerk and anaesthesia over the front and sides of 
the thigh and the inner side of the leg and foot. It has occurred in 
1.7 per cent, of labor cases and may result from stab wounds of the 
thigh, in which case the iliacus escapes involvement. Neuritis of its 
external cutaneous branch (multiple neuritis, alcoholism, nicotinism 
or gout) may cause isolated anaesthesia over the lower outer half of 
the thigh, paresthesia or marked hyperesthesia; the last condition, 
known as meralgia, was described by Bernhardt and Roth and is 
usually neuritis but may be due to pressure from varicose veins. It 
is noted, chiefly, on standing or walking. In 1900 Musser and Sailer 
collected 99 cases (74 per cent, in men). 

Pressure on the cord at the fourth lumbar roots produces the same 
result as a partial lesion of the ant. crural nerve, as paralysis of knee 
extensors, loss of knee-jerk and anaesthesia of anterior part of thigh, 
but foot clonus is present. Disease of the anterior horns on one side 
may exceptionally occur in adults, but its wider prevalence and sensory 
exemption are usually sufficiently distinctive. Caudal lesions are 
usually bilateral. 

Obturator Nerve. — This nerve is rarely alone involved save during 



1180 DISEASES OF THE XERVOUS SYSTEM 

parturition. Its paralysis affects the thigh adductors, so that the knees 
cannot be crossed, and the pectineus and ext. obturator, so that impair- 
ment of outward rotation of the thigh results. Sensory symptoms 
concern the hip and knee joints, which sometimes show trophic dis- 
turbance. The pain of hip disease is referred to the knee by the 
obturator nerve. 

Superior Gluteal Nerve. — This arises from the lumbosacral cord, 
being intermediate between the lumbar and sacral plexuses. Its rare 
isolated involvement results in loss of thigh abduction and circum- 
duction (gluteus medius and minimus). 

The sacral plexus (half of the fourth, the fifth lumbar and the first 
four sacral nerves) supplies motion to the extensors and rotators of 
the hip, flexors of the knee and all the foot muscles, and sensation 
to the gluteal region, the back of the thigh, outside and back of the 
leg and most of the foot by the gluteal nerves and the two sciatic 
nerves. The lesser sciatic is affected only in disease of the plexus: it 
is often involved in pelvic inflammation and tumors, parturition, 
traction in leg deliveries, plexus neuritis and diseases of the hip. 

Great Sciatic Nerve. — This is the largest, the most exposed through- 
out its course and hence the most frequently diseased nerve of the lower 
extremity. Paralysis of the gluteus maximus interferes with rising more 
than with walking. A lesion near the sciatic notch paralyzes the exten- 
sors of the hip, the flexors of the leg and all muscles below the knee. If 
the lesion lies below the upper third of the thigh, the flexors of the 
leg may escape involvement, and walking is still possible, even though 
all muscles below the knee are paralyzed, if the ant. crural nerve for 
the hip flexors and knee extensors is intact. Sensation is lessened 
over the outer half of the leg, most of the dorsum of the foot and all 
of the sole. Wasting is marked over the back of the thigh and perforat- 
ing ulcer of the foot may develop. It has two branches: (a) the 
external popliteal or peroneal nerve, involvement of which causes 
paralysis of the tibialis anticus, peronei, long toe extensors, extensor 
brev. digitorum ; the ankle cannot be flexed dorsally, the first phalanges 
of the toes cannot be extended, adduction and lifting the inner edge 
of the foot is difficult and abduction and lifting its outer edge is im- 
possible. Foot-drop results and contracture assumes the equinovarus 
type. This nerve is the analogue of the musculospiral in the arm. 
Wasting is often observed and the anaesthesia covers the anterior 
outer half of the leg and the dorsum of the foot, (b) Internal popliteal 
nerve, involvement of which affects the popliteus, tibialis posticus, 
long flexors of toes and all the foot muscles except the extensors; 
plantar flexion, abduction of the foot, inability to stand on tiptoe, 
talipes calcaneus and the claw foot from overextension of the proximal 
and overflexion of the second and third phalanges result. Sensory 
alterations are variable; anaesthesia mav be observed on the outer 



DISEASES OF SPINAL NERVES 1181 

lower posterior part of the leg and on the sole of the foot. Its plantar 
branches are rarely affected alone; there may be (i) paralysis of the 
internal plantar nerve, which is analogous to the median; anaesthesia 
on the inner part of the sole and the plantar surface of the three inner 
toes and one-half of the fourth; paralysis of the short toe flexors, 
plantar muscles of great toe (except the abductor) and the two inner 
lumbricals; the big toe is overextended, "the hammer toe"; (ii) paral- 
ysis of the external plantar nerve, which is the analogue of the ulnar, 
produces anaesthesia of the outer half of the sole, little toe and one-half 
of the fourth, paralysis of the accessory flexor, small toe muscles, all 
the interossei, two outer lumbricals and great toe adductor; the results 
are serious, walking being impaired by flexion of the second and third 
and extension of the first phalanges. 

Caudal Lesions. — (See Spinal Localization.) 

Sciatic Neuritis. — Sciatica, Ischialgia, Malum Cotunnii (Cotugno,. 
1764). — Sciatica is, after facial neuritis, the most frequent isolated 
form and is rarely simply neuralgic. 

Etiology. — General Causes. — (a) Sex and age; 88 per cent, of 
cases occur in men; 16 per cent, in persons between twenty and 
thirty, 31 per cent, between thirty and forty, 25 per cent, between 
forty and fifty, and 18 per cent, between fifty and sixty years of age. 
It is very rare in children. (6) Acute infections, rheumatism, and 
grippe, are causative, (c) Intoxications; gout, fascial rheumatism 
(sometimes by extension from lumbago), and diabetes, are factors. 
(d) Anaemias and neuroses are much less significant than in true 
neuralgia. 

Local Causes. — These include (a) spinal affections, tumor, and 
neuritis of the cauda; (6) abdominal and pelvic disease, as aneurysm, 
abdominal and pelvic tumors or inflammation; (c) cold; exposure 
and dampness, favored by certain occupations; (d) trauma to the 
spine, pelvis, hip or peripheral course of the sciatic trunk or branches, 
as from the use of forceps or pressure of the head in labor, fractures 
or dislocations, falls, protracted sitting or riding, use of the sewing 
machine, marching, vigorous contractions of the leg flexors, peripheral 
pressure by popliteal aneurysm, tumors, callus or varicosities. 

Pathology. — In the infrequent autopsies or in surgical stretching 
of the nerve, its sheath shows perineuritis with oedema and in some 
cases increase of connective tissue or varicosities of the sheath vessels, 
especially in the middle thigh. Sometimes interstitial neuritis is found. 

Symptoms. — The symptoms are unilateral and chiefly sensory, as 
pain and tenderness over the sciatic roots, trunk and branches, (a) 
The onset of pain is usually gradual but is sudden and febrile in some 
rheumatic cases. It is usually constant, with exacerbations which 
in some cases are agonizing. The pain descends more often than it 
ascends; it sometimes radiates to the buttocks and crural region, even 
into the other leg. Gowers attributes the local pain to perineuritis, 
and the distant pain to interstitial neuritis. Any movement which 



1182 DISEASES OF THE NERVOUS SYSTEM 

increases sciatic tension increases or renews the pain (Lasegue's 
phenomenon); pain is increased or initiated by flexing the hip and 
extending the knee, walking, stooping, or by defecation. The patient 
seeks positions which spare stretching of the nerve and its compression 
by the muscles; he may lie on the opposite side with the thigh extended, 
knee flexed and foot extended, or on his back with hip and knee flexed 
and foot extended; in standing, he rests on the sound leg, and in 
protracted cases scoliosis develops (ischias scoliotica, Albert, 1886), in 
which the lumbar convexity is toward the diseased side, heterologous 
scoliosis, which usually disappears with the disease; a homologous 
scoliosis (with the lumbar concavity toward the affected side) may result 
in case the muscles of that side become spasmodic, (b) Tenderness may 
be detected over the entire course of the nerve or in certain locations 
only; (i) over the lumbar region; (ii) near the sacrum and post. sup. 
iliac spine; (hi) at the lower gluteal fold where it leaves the sciatic 
notch; (iv) between the tuber ischii and trochanter; (v) especially 
over the middle of the posterior surface of the thigh; and (vi) in other 
lower areas of distribution over the popliteal space, head of fibula, 
calf, internal and external malleoli and sole. The enlarged nerve may 
occasionally be felt. Pain is often experienced in the hip and sciatic 
notch when pressure is made in the popliteal space. (c) Other symp- 
toms are less frequent, as vasomotor changes, herpes, muscular 
cramps, twitchings, fibrillation or wavy movements (myokymia); 
there is usually some diminution in the electrical excitability or perhaps 
an increase, but there are rarely marked evidences of the degenerative 
reaction; muscular atrophy may occur from disuse or neuritic atrophy; 
sciatic paralysis may occur; hyperesthesia, paresthesia, or in severe 
cases anesthesia, may develop in the posterior part of the thigh, leg 
or foot; very rarely there is polyuria or glycosuria. The patellar 
reflex is usually normal, the Achilles reflex is often decreased or absent 
and Gibson found the cremasteric usually increased. 

Diagnosis. — (a) The etiological factor should be sought. (6) The 
pelvis should always be examined in women and the rectum in both 
sexes, because compression produces more distant than local pain; 
the urine should always be examined for sugar and albumin; and 
free catharsis and bowel lavage should always be given, (c) Bilateral 
sciatic pain suggests disease of the cord, especially tabes, a lesion of 
the cauda, in both of which there is no sciatic tenderness, or it prompts 
examination for sugar, (d) Coxitis, sacro-iliac or psoas disease present 
appropriate local signs, without however Lasegue's sign or sciatic 
tenderness, both of which are also absent in (e) hysteria. (/) Muscular 
rheumatism is irregular and is chiefly confused with pain over the 
sciatic branches. 

Prognosis. — The prognosis is generally good, in regard to the ulti- 
mate outcome. It depends on (a) whether the affection is primary, as 
from cold, or secondary, as from disease of the cord, or pelvic neo- 
plasm; (b) the amount of rest which the patient accepts; (c) the 
intensity of the neuritis, which may extend to the lumbosacral plexus; 



DISEASES OF SPINAL NERVES 1183 

and (d) the chance (in 33 per cent.) of relapse. The average course 
is from two to eight weeks, but cases may last over a year, indeed one 
to three or exceptionally six to thirty years. 

Treatment. — (a) Treatment is that of the cause; the salicylates, 
in some, but unfortunately few, cases afford relief; gouty or syphilitic 
taints may be benefited by colchicum or antisyphilitic remedies, 
which are often given as a last resort in other cases, (b) Rest in bed 
is the most important indication. In this, the use of Wier Mitchell's 
long splint is often beneficial, (c) Counter irritation by blisters over 
the nerve's course or by touching the tender or painful points with 
the hot iron, may give temporary though rarely lasting relief, (d) 
Analgesics and narcotics may be used. Acetanilide has little effect. 
Gelsemium (fl. extr. tt£ ii) at intervals of two to four hours, not in- 
frequently gives relief, though it is necessary to watch for pulse weak- 
ness and cutaneous tingling. Codeine and atropine should be given 
before resort is had to morphine, though morphine is often inevitable, 
but always dangerous. Chronic morphinism may be promoted by 
severe pain, the long course, and the tendency to relapse. Hypodermics 
of cocaine are very beneficial, though this method is attended by the 
same danger. Simple hypodermics of water are sometimes valuable, 
and the author has seen good results from deep hypodermatic use of 
Schleich's solution given in quite large amounts over sensitive points. 
Lange recently advises the use of 160 c. c. of 0.1 per cent, eucain 
into the muscle and nerve at the sacrosciatic foramen. Injections of 
chloroform and ether are recommended, but should be avoided because 
of the possibility not only of sloughing but also of accentuating the 
neuritis, (e) Acupuncture, the old Chinese treatment, is recom- 
mended by Gibson; it resulted in complete relief in 56 per cent, of 
his cases, much improvement in 32 per cent., slight benefit in 10 per 
cent., and failure in but 2 per cent. (/) Massage may be given. Negro 
has obtained results from frequent and severe local rubbing and rolling, 
over the nerve trunk, (g) Electrotherapy may aggravate the pain and 
is at least of uncertain value. Galvanism is reported to have helped 
some cases, (h) Nerve stretching may be effected by extension by 
weights, although it is rarely tolerated by the patient in personal 
experience. The direct exposure of the nerve has justly fallen into 
disuse, for the same results attend simple stretching, which should be 
performed under anaesthesia. The hip should be strongly flexed, the 
knee extended, the foot dorsally flexed, and the pelvis firmly immobi- 
lized. Ordinary care prevents luxation of the hip. The results were 
excellent in half of twenty personal cases, and were seemingly curative 
in seven. 



1184 DISEASES OF THE NERVOUS SYSTEM 

V. NEUROSES. 

HYSTERIA. 

Definition. — The neuroses are nervous affections, provisionally 
isolated and often designated " functional," since no anatomical basis 
has yet been discovered. Hysteria is difficult to define. Mobius 
considers it "a state in which ideas control the body and produce 
morbid changes in its f unctions.' ' The school of Charcot has estab- 
lished the psychogenic nature of hysteria. It is a cerebral, cortical 
condition, in which the sensory and motor centres are affected, the 
perception, association and recollection of ideas are disturbed and 
trophic and vasomotor disorders occur. As its name implies, hysteria 
was long thought to be due to the uterus; Sydenham first called it a 
nervous affection. 

Etiology. — (a) Age: It is most frequent at puberty and adolescence 
(fifteen to twenty-five years). It is occasionally seen in children (six to 
ten years or even earlier), and rarely in middle or advanced life, (b) 
Sex: Women are six to ten times as frequently affected as men, 
although in the lower French classes, it is more frequent in males. 
(c) Race: The Jewish, Latin and Slavic races are most . frequently 
affected, id) Heredity: Charcot, and most of the modern French 
school, hold that this is the sole cause, other factors being only agents 
'provocateurs. Parental intoxications, toxaemias, constitutional diseases, 
as gout, diabetes, arthritis deformans and a neurotic taint are im- 
portant in the transmission of a congenitally weak nervous system. 
(e) Acquired hysteria may be due (i) to various intoxications, notably 
lead, alcohol and drugs; (ii) to infections, as typhoid, malaria, diph- 
theria, and syphilis; (iii) to constitutional maladies, as gout, diabetes, 
chlorosis, secondary anaemias or cancer; (iv) to exhaustion from mental 
or physical overwork or excesses ; (v) to emotional disturbance of any 
kind; (vi) to trauma, especially factors involving psychical shock, (vii) 
It may occur as an associate with chronic nervous disease, epilepsy, 
syringomyelia, tabes, brain tumor, and multiple sclerosis, (viii) Imi- 
tation is an important factor in schools, hospitals, and at religious re- 
vivals; endemics occasionally occur now as they did in the middle ages. 
(Refer to Zola's Lourdes.) Reference to the sexual organs as causes 
and to reflex hysteria is purposely omitted, because they have no 
etiological bearing. The factors enumerated under acquired hysteria 
are, according to the French School, merely incidental causes, making 
manifest the latent hereditary disposition. 

Symptoms. — There is no typical clinical picture, and the disease is 
much more commonly polysymptomatic than monosymptomatic. 
French writers distinguish two main groups of symptoms, the stigmata 
and accidents. 

The stigmata are usually but not necessarily persistent symptoms. 



HYSTERIA 1185 

1. Sensory Stigmata. — Sensory symptoms are present in 85 per 
cent., are more frequent than the motor and are often combined with 
them, (a) Hysterical anesthesia in some form is very seldom absent. 
It must often be looked for, but the fact should not be too obviously 
suggested to the patient. It varies in degree and form. It may be 
absolute, affecting appreciation of touch, pain, heat and cold. Anal- 
gesia is its most common form and, in decreasing order of frequency, 
there may be complete anaesthesia, hypaesthesia, loss of tactile sense, 
loss of all sensation save to the faradic current, or loss of faradic 
response alone. In the mucosae the same deficit frequently occurs, 
and sometimes the bones, ligaments, joints and muscles are likewise 
anaesthetic or analgesic. The distribution varies. In rare cases there 
is universal cutaneous and muscular anaesthesia; the following are 
more frequent: Hysterical hemianesthesia, which involves precisely 
one-half of the skin, often the accessible mucosae and the special senses ; 
segmentary or geometrical anaesthesia, which affects one limb or part 
of it, is variously described as " mitten, or stocking" anaesthesia, and is 
frequently associated with motor or special sense disturbance in the 
part affected, as paralysis, aphonia, amblyopia, and deafness; and 
insular anaesthesia, which affects small areas, and is therefore fre- 
quently overlooked. 

Characteristics. — The anaesthesia is psychical, is associated with 
the functions of the part affected and does not follow the area of 
distribution of the peripheral nerves or the spinal segments ; it is not 
noted by the patient, at least until suggested; fine movements may be 
conducted with the aid of the eyes, as the using of a pen; it may be 
localized because of injury or disease in the part. Most of the reflexes 
which are usually altered by organic disease, remain normal, as the 
pupillary, lachrymal, epigastric, cremasteric, patellar and organic 
reflexes, while the pharyngeal in 90 per cent, of cases is lost as well as 
the plantar (though the knee reflex remains); the anaesthetic areas 
may last during life, but they vary, move even under examination 
(Patrick), or disappear from emotion, strongly aroused attention, 
drugs or on application of various indifferent substances, as metal or 
wood (transferring it to the opposite side). 

Hysterical hyperesthesia and hyperalgesia are very common in 
localized areas, but never in universal or hemiplegic distribution. 
They occur spontaneously, or from attention directed to a part or 
organ, as by traumatism. A joint may be affected with or without 
contracture (Brodie's joints), and this often leads to great and un- 
fortunate errors. There is sometimes hypaesthesia in the sphere of any 
of the special senses. The feeling of a nail in the top of the head 
(clavus hystericus), sensitive spots in the mammae, epigastrium, groins 
or spine are the most common forms and may occur in the midst of anaes- 
thetic areas. The so-called ovaralgia is found more often in the left side 
and is cutaneous; it has no relation to the location or to disease of 
the ovary; it occurs also in men and in women normal as to the pelvis. 
Because hysterical attacks have been initiated and sometimes stopped 

75 



1186 DISEASES OE THE NERVOUS SYSTEM 

by pressure over this and other sensitive areas, they have been called 
hysterogenic points or zones, but attacks are only so produced in patients 
already hysterical and the hysterical seizure on pressure results only 
from some associated memory on the part of the patient ; they are often 
the result of suggestion. The special senses. Taste and smell may be 
dulled or hypersensitive, and hearing may be blunted, or more rarely 
complete central deafness results, winch is usually associated with 
anaesthesia in and about the auditory meatus. Complete loss of vision 
is both rare and transitory. Hemiopia and scotomata are almost 
always organic and not hysterical. Partial stigmata are more com- 
mon. In most cases there is concentric contraction of the visual field, 
which is usually bilateral, but unequal on the two sides, and generally 
greater on the side of the cutaneous defects. Concentric contraction 
of the field for colors (dyschromatopsia) is more characteristic, even 
pathognomonic. In the normal eye, blue has the largest field, then 
yellow, orange, red, green and violet; in hysteria the red field is often 
wider than the blue and is the last color lost. Achromatopsia designates 
the complete loss of color perception. Errors in accommodation 
(always excluding abnormal corneal curvatures) may cause double 
images in one eye — the other being closed — (monocular diplopia,) 
triple images (polyopia), or large or small images (macropsia, mic- 
ropsia). In hysterical amblyopia, impairment of vision in the affected 
eye is decreased when the other eye is opened. 

2. Motor Stigmata. — These are much less conspicuous but fore- 
shadow the motor accidents described later. Voluntary movements 
are weaker, more clumsy, slower, less coordinate than normal, and 
there is a slight tendency toward contractures. 

3. Mental Stigmata.— These are in certain cases so pronounced 
as to justify the term psychosis. Hysteria is always a psychical affec- 
tion. The most conspicuous alienation is impairment of memory 
{amnesia), which concerns memory in the ordinarily accepted sense, 
as memory for persons, things, words, hysterical paroxysms experi- 
enced, etc., or concerns memory and associations for speech, writing, 
walking or standing. The amnesia, like the paralysis or anaesthesia, 
is functional, and like them, returns, save in rare cases. Mental power 
is distinctly decreased, will power is lost (aboulia) or lessened, and the 
patient becomes the ready victim of impulses, impressions, sugges- 
tions, fixed ideas and misconceptions both on his own part and on 
that of others who incorrectly consider him deceitful, vain or erotic. 

Accidents. — The accidents of hysteria are the incidental attacks, 
also called seizures or paroxysms. They are usually transient or inter- 
mittent, but may become fixed and are then ranked as stigmata. 

1. Motor Accidents. — (a) Convulsions occur in 54 per cent. 
of all and 84 per cent, of female hysteria. They are much less fre- 
quently the hysteria major (grande attaque of Charcot) than the partial, 
modified type (hysteria minor). The "grand attack" (Charcot, 
Richer) comprises (i) a prodromal stage, with mental depression or 
exaltation, palpitation, vasomotor symptoms, nausea, polyuria, an 



HYSTERIA 1187 

aura beginning in the epigastrium and culminating in feelings of 
choking (globus hystericus), vertigo, and unconsciousness; (ii) a 
period of epileptiform convulsions (so-called hystero-epilepsy) in which, 
in exceptional cases, there may be biting of the tongue or even the cry 
of epilepsy; the face is at first pale, then red; the teeth are ground; 
the convulsion is most pronounced on the anaesthetic side, toward 
which the face turns; the tonic spasm lasts less than two minutes, and 
is often characterized by stupor, stertor and slow wide movements of 
supination, circumduction, and overextension, for the trunk and body 
are tetanically rigid; then the clonic spasm develops, with sobbing 
respiration, audible swallowing, abdominal rumbling and small 
clonic movements. Resolution follows slowly, (hi) There is a period 
of "clownism," characterized by contortions and grand movements, 
as opisthotonos (arc de cercle), bowing movements, violent struggling, 
screams, strikes and bites, (iv) There is next a period of " passional 
attitudes," in which the subject mimics terror, rage, joy, and love; 
this is followed by (v) a stage of delirium with hallucinations, perhaps 
of animals (zoopsia). The entire attack covers fifteen to thirty minutes 
and frequent repetitions constitute the "status hystericus." 

The partial attack contains some of the elements of the major type, 
and infinite variations occur; in the vertiginous type, there is vertigo 
and sometimes the other features of Meniere's disease; the globus 
type is extremely common; the epileptiform variety closely resem- 
bles epilepsy; there are also tetanic, emotional and syncopal types; 
trance-like sleep, with catalepsy in which the limbs retain any atti- 
tude given them, with sleep, which is apparent only, for the subject 
later recalls everything; there may be attacks of somnambulism, in 
which patients run miles or even undertake distant travel without 
recollection of the transpired interval, (h) Paralysis is an accentua- 
tion of the stigmatic muscular weakness. In over 50 per cent, it 
develops after convulsive paroxysms; again it follows emotional 
causes, traumatism or organic brain disease. It develops suddenly 
or gradually; it assumes the paraplegic five times as often as the 
hemiplegic form; the monoplegic variety is less frequent; the tri- 
plegia, diplegic (quadriplegic) or crossed forms are most common. 
They are rarely complete; often automatic (gesticulatory) movements 
may be seen; the antagonistic muscles are also involved, thus, in 
attempted flexion of the knee the knee extensors contract ; remissions 
and relapses may occur; the paralyzed part may be limp or contrac- 
tured; the paralyses may be ephemeral or life-long in duration; 
paralysis may be "ideal," i. e., only for standing or walking. Vaso- 
motor changes and oedema are rare; Wier Mitchell described a hemi- 
cedema; the tendon, skin and electrical reactions are usually normal, 
although the tendon reflexes may be increased. Hysterical hemiplegia 
occurs three times as frequently on the left as on the right side. Its 
differentiation from organic hysteria is based on Babinski's table 
on the following page. 



1188 



DISEASES OF THE NERVOUS SYSTEM 



Organic Hemiplegia. 



-Hysterical Hemiplegia. 



Coma: often complete. 



Reflexes: tendon and bone reflexes abol- 
ished at first; later increased. Ankle 
clonus. 

Cutaneous reflexes (abdominal and 
cremasteric) early lessened or abol- 
ished; Babinski toe sign; lachrymal 
reflex abolished. 

Paralysis: (1) Unilateral ; (2) not sys- 
tematized; face, arm and leg are 
weak during bilateral synergetic 
movements. (3) Involves subcon- 
scious as well as conscious voluntary 
movements, producing the platysma 
sign (lessening of its contraction on 
the hemiplegic side, e. g. on opening 
the mouth forcibly), and the com- 
bined flexion of the thigh and trunk 
(when the patient attempts to sit up). 
(4) Paralysis slowly improves some, 
but is not variable. 

The tongue deviates slightly toward the 
paralyzed side. 

Lower muscular tone, as lowering of the 
eyebrow or exaggerated flexion of the 
forearm, especially in early cases. 

Contracture cannot be voluntarily repro- 
duced; at first flaccid paralysis, then 
contracture. 



Hemianesthesia: rarely total; mostly 
of stereognostic and muscle sense; in 
general rare; coarser; more lasting 
when present; often with bilateral 
hemianopsia. 



Rarely complete (automatic movements 
often persist). 

Never abolished; no clonus (or only a 
spurious ankle clonus due to contrac- 
tion of the calf muscles, Gowers). 

Skin reflexes normal; no toe sign. 



Never abolished (Spiller). 

(1) Not always unilateral; if face in- 
volved, usually on both sides. (2) 
Paralysis sometimes systematized; 
and hemiplegic side functionates 
perfectly in bilateral synergetic move- 
ments. (3) Subconscious voluntary 
movements are not involved; ab- 
sence of the platysma sign and that of 
combined flexion of the thigh and 
trunk. (4) Variable paralysis, im- 
provement alternating with relapses. 
Absolute aphasia with ability to 
write (Charcot). 

Very slightly, very greatly or even 
toward the sound side. 

None. Asymmetry of the face is due to 
spasm, and exaggerated flexion of the 
forearm is absent. 

May be reproduced: variable paralysis, 
now persistently flaccid, now spastic 
from onset; flaccidity with increased 
reflexes highly characteristic. 

Often total, involving special senses, 
mostly involving pain and pressure 
sense; frequent; variable in duration 
and location; usually with concentric 
contraction of visual field, and some- 
times with crossed amblyopia. 



In hysterical paraplegia there are usually no trophic changes, no bed- 
sores, no electrical alteration, no incontinence of urine or faeces, and 
rarely retention of urine; concomitant sensory changes are significant, 
but many errors in diagnosis are made. Hysterical monoplegia usually 
occurs with anaesthesia of even greater extent and segmental distri- 
bution; it is lawless and illogical, viewed from the standpoint of 
organic disease. In astasia-abasia (Charcot and Blocq), the patient 
is unable to stand or walk, although the muscles concerned may be 
efficient in other movements. The condition is essentially hysteria, 
although it was thought to result from neurasthenia and hypochon- 
driasis. Lesser degrees are called dystasia or dysbasia. The term 
tasobasophobia is self-descriptive. Mobius' akinesia algera is 
milar. (c) Hysterical contractures precede, succeed or alternate with 



HYSTERIA 1189 

paralysis, or occur alone, but, as Church well says, they are "rigid 
palsies"; they usually persist during sleep and yield to ether anaesthe- 
sia, save in severe protracted cases with great fibrous transformation 
and irremediable deformity; they develop and terminate suddenly or 
gradually; their causes of onset and distribution are as in paralysis. 
In the arms, contracture of the flexors predominates; in the legs, that 
of the extensors (club foot). Various spinal deformities may develop, 
most frequently from pseudosciatica. Wier Mitchell has seen the 
muscles so contracted as to resemble actual muscle tumors. It is still 
stated that the face always escapes paralysis, but its lower portion may be 
weak; more often, however, it is contracted early, even when paralyzed; 
hemispasmus glossolabialis and trismus have been observed. Spastic 
or pseudo-ptosis may resemble the paralytic form, but spasticity, the 
lowered or more level eyebrow, and the concentric or parallel folds in 
the lid, are distinctive of contracture. The ocular muscles are seldom 
involved; voluntary movement may be impossible, but associated and 
reflex movements are normal; convergent squint may occur, but never 
the divergent type nor contracture of a single rectus or oblique muscle ; 
pain suggests hysteria. The pupils are usually said to be normal but 
Karplus maintains that the light reflex is lost during convulsive seizures. 
Organic disease of the hip may be simulated; local hysterical oedema 
may occur. Brodie (1827) first drew attention to this group of cases, 
and later Duchenne. Many avoidable diagnostic errors are constantly 
made, (d) There may be rhythmical spasms, tremor, or tic. Rhyth- 
mical spasms, chorea major, the saltatoric chorea {v. i.) and local 
manifestations, as barking cough or the various tics, may occur. 
Hysterical tremor is wholly a "rest tremor"; that is, it occurs without 
voluntary movement. It may resemble the senile, Basedow, or lead 
tremors, or that of paralysis agitans or may be combined with them. 
It rarely simulates the intention tremor of multiple sclerosis. 

2. Sensory Accidents. — These are frequent, and are often severe 
and painful. Headache may occur; it is often dull or may be severe; it 
may be superficial or deep; it may resemble trigeminal neuralgia, 
migraine or the headache of organic disease as tumor. Meningitis 
(hysterical pseudomeningitis) may be closely counterfeited. Spinal 
or vertebral pain is frequent and sometimes suggests tumor or caries. 
One and three-tenths percent, of cases of sciatica are said to be hysteri- 
cal. Joint disease and various visceral lesions (v. i.) may be closely 
mimicked. Dieulafoy (1905) collated 59 cases of hysterical blindness, 
in 5 of which this accident was the only symptom. 

3. Visceral Accidents. — (a) Cardiac accidents include tachycardia, 
palpitation and pseudo-angina pectoris, (b) Respiratory accidents: 
Aphonia, usually attended by normal capacity to cough and often also 
to sing, has been described under paralysis of the vocal cords. It is 
usually due to an "idea, " as in aphasia of the motor type, which allows 
the patient to write. Stammering, cough, and cries, may be provoked 
by local nasopharyngeal disease. Dyspnoea, resulting from paralysis 
of the diaphragm, and laryngeal spasm have already been considered. 



1190 DISEASES OF THE XERYOUS SYSTEM 

Rapid breathing (tachypncea) also occurs. The combination of 
dyspnoea, aphonia and paralysis of the diaphragm constitutes Briquet's 
syndrome. Haemoptysis may occur, usually in the course of phthisis, 
but sometimes without it, possibly as a vasomotor derangement, since 
the blood is thin; one fatal case is on record. (c) Digestive accidents : 
Hysterical anorexia results from cortical conception, stomach pain, 
dysphagia from spasm, or simple sensory perversion ; it may endure for 
weeks and cause extreme inanition or even death. Hysterical (pseudo-) 
hydrophobia is an analogous aversion to water. Vomiting is sometimes 
simulated by protracted globus or oesophageal spasm, in which the 
food is simply regurgitated. Vomiting itself may be occasional, or 
attacks may last weeks or months, often with remarkably little malnu- 
trition; it is rarely faecal but substances injected by rectum may be 
vomited in a few hours, or again may be blood-tinged, possibly from 
vasomotor disturbance or more often from actual disease, as round 
ulcer. Ulcer may also be simulated by pain and tenderness, which 
are surprisingly well confined not to one spot, but to the exact outlines 
of the stomach. The vomitus contains vicariously large amounts of 
urea when the urine is suppressed. Eructations are frequent and so 
much gas escapes that one must conclude that air has been swallowed ; 
this also probably causes tympanites, in which swallowed air reaches 
the gut through the incompetent pylorus (Ebstein). Phantom tumors 
or spurious pregnancy (pseudocyesis) are explained by Gowers as 
protrusion of the distended bowel by tonic contracture of the diaphragm. 
Peristaltic unrest, diarrhoea on eating, enteritis membranacea, spastic 
constipation, simulation of peritonitis, rectal stricture or intestinal 
obstruction also occur, (d) Genito-urinary accidents : Anuria in some 
cases has existed for ten days without uraemia. Renal pain is not 
frequent, but hyperesthesia of the bladder is common. The urine is 
often greatly increased, with low specific gravity and solids. During- 
attacks of the major type, the solids are reduced, the urea one-third 
and phosphates one-half; the phosphates, which normally have a 
proportion of 3 of the alkaline to 1 of the earthy phosphates, show 
rearly an equal proportion of each. Depression of the genital functions 
is more common than exaltation; anaesthesia is frequent; vaginismus 
may be observed. Lower has found that the hysterical ovarian and 
other genital pains have no relation to local pelvic disease, a rather 
gratifying gynaecological observation. 

Hysterical fever is a disputed topic. It is an established fact that 
severe forms may suffer a rise to 105 or 110° or higher. With visceral 
manifestations, this may lead to a diagnosis of meningitis or peritonitis; 
but on the other hand the possibility of simulation by the patient rub- 
bing the thermometer, or more important still, the possibility of con- 
fusion with tuberculosis or typhoid, must always be kept in mind. 

4. Vasomotor and Trophic Accidents. — These are rare. Ery- 
thema is the most common. Gangrene, falling out of the hair or 
nails, Raynaud's local asphyxia, cutaneous hemorrhages (crucifixion 
stigmata, stigmata diaboli), bloody sweats, lachrymation, haemoptysis,. 



HYSTERIA 1191 

lisemateinesis, sudden tender swellings in the mammae, and angio- 
neurotic oedema, which is sometimes blue in color, have been recorded 
in exceptional cases. 

Course and Prognosis. — The course is always chronic. If we look 
on the disease as congenital, the prognosis is poor as to total recovery, 
especially with fixed psychical alteration and major manifestations. 
Jolly remarks that complete recovery is as rare as death, which rather 
overstates the facts. In mild forms practical recovery may follow, but 
relapses may occur on disproportionately slight provocation. The out- 
look is better in infantile and adolescent forms than in those of middle 
or advanced life. The stigmata may be ephemeral or life-long. Mar- 
riage may prove beneficial in light cases, but, with maternity, it is 
injurious in the severe types; marriage must never be regarded as a 
therapeutic agent. 

Diagnosis. — The stigmata, mental, motor and sensory, are highly 
characteristic. The accidents are either unequivocally hysterical, or 
prove hysterical after consideration of their associations or history. 
The real danger lies in overlooking concomitant disease (a) nervous, as 
multiple sclerosis, brain tumor, paretic dementia; (b) postinfectious 
hysteria as hysteria plus neuritis; (c) lung, heart and other visceral 
diseases, all of which, as Sydenham remarked, may resemble hysteria. 
Simulation does not include the common borrowing or mimicry of 
symptoms by hysterics; simulation of hysterical stigmata and accidents 
is practically impossible. 

Treatment. — 1. Prophylaxis. — This is possible when the earliest 
manifestations occur in childhood. Home treatment is frequently 
impracticable because of the family tendency. The etiological factors 
must be studied, especially the hygiene and the hours of sleep. Useful 
occupations, as out-of-door gardening, are preferable to less whole- 
some and more artificial plans of distraction. Cultivation of the car- 
dinal virtues, courage and self-control, is sought. Servants who teach 
fear of the dark and tell fairy stories should be watched. Self-control 
should be insisted upon in adult cases. 

2. General Treatment of the Cause. — As the disease depends 
on disturbed cortical relations between the psychical and material 
processes, the principal treatment must be psychical. The "fixed 
idea" must be grasped and eradicated, which is best accomplished in 
ordinary circumstances by isolation of the patient from home or from 
other psychical or emotional circumstances surrounding the inception 
of the disease. Then the undue susceptibility incident to the disease 
may be turned to therapeutic advantage by the self-confidence of the 
physician and by his covert suggestions. The Wier Mitchell rest-cure 
may result in great benefit, and later "vague hints regarding the 
curative power of nature," and fresh air and sunlight may captivate the 
patient. Symptoms must not be suggested to the subject, as anaes- 
thesia or pelvic disease, and examinations, especially of the pelvis, 
should be omitted. Hysterics should not be allowed to associate with 
each other for obvious reasons. This general plan is psychotherapy. 



1192 DISEASES OF THE XERVOUS SYSTEM 

which of course might include hypnotherapy, as advocated by the 
Nancy school, Bernheim and others. Hypnotism is generally dan- 
gerous in its ultimate and often in its immediate effects; though the 
definition of hypnotism may be a matter of difference or of dispute, 
its danger is shown by the fact that Striimpell considers it an "artificial 
hysteria/' and Fere defines it as a "transformation of hysteria." "It 
is easier to make a sound person hysterical by hypnosis than to cure a 
hysterical one by it"(Liebermeister). Treatment is sometimes frus- 
trated by the patient's vanity. Successful treatment requires unusual 
tact, profound knowledge of human nature, strong sympathies (but 
dominance of the patient) and enormous optimism. Of course certain 
single qualities, in an ignorant quack, may effect cures. 

3. Special or Symptomatic Treatment. — (a) In relieving pain, 
the physician should first acknowledge its existence and intensity in 
order to soothe the patient, and should then apply blisters, liniments, 
or the galvanic current, with the anode on the painful area. Ovaralgia 
in most cases should be ignored; in exceptional cases pelvic surgery has 
given relief; Lower's position has already been mentioned (v. s.). 
(b) Convulsions are treated by dashing cold water into the face, by 
suggestive measures, or, if severe, by etherization. Bromides are of 
little value, valerian is sometimes beneficial and turpentine is recom- 
mended by Gowers as most efficient, 10 drops of the oil being given 
until slight vesical symptoms appear. Pouring water into the mouth or 
nose, which causes coughing, or Hare's method of holding a towel over 
the nose and mouth for 15 to 20 seconds, may also serve, (c) Paralysis 
and contracture should receive early treatment, for late neglected cases 
may necessitate surgical intervention, as tenotomy. Massage, faradism, 
blisters, and fixation in new postures are indicated, and especially 
should their significance be minimized and the patient be assured that 
they are not organic. In two cases the author has seen the paralysis 
disappear at once on administration of asafcetida in an effervescing 
mixture, (d) Anaesthesia should be ignored, (e) Aphonia is treated 
by intralaryngeal faradization. Laryngeal and other respiratory 
spasms usually answer to energetic traction on the tongue, and anaes- 
thesia or tracheotomy is rarely necessary. (/) For insomnia, the 
patient should retire at an absolutely regular hour; nervines should be 
given rather than bromides, and hot milk should be very slowly sipped. 
(g) Dysphagia, vomiting and anorexia may be treated by rectal feeding, 
or by forced feeding through the stomach tube, which is the better 
method. Constipation is often obstinate, and its mixed spastic and 
paretic character is shown by the fseces which are like those of sheep. 
Free administration of olive oil by mouth and rectum, cold abdominal 
compresses and endorectal galvanization are usually effective. 



NEURASTHENIA 1 193 



NEURASTHENIA. 

Definition. — Neurasthenia is a diffuse neurosis, which affects the 
entire nervous system, but chiefly the brain; it is characterized (a) 
by morbid irritability of the nervous system with a tendency to its 
rapid exhaustion ("irritable weakness"), and (6) particularly by 
psychical, motor, sensory, vasomotor, secretory and vegetative distur- 
bances in function. The nervous tissue responds unduly to stimuli, 
its reaction time is short, and ready exhaustion results. It seems 
probable that the slight cellular and protoplasmic changes in nerve 
cells, noted by Hodge to follow fatigue, may have some bearing on 
its pathology. The affection was described and named by Beard in 
1869, whose description was first received with some skepticism 
and ridicule abroad, but later gained universal recognition. It is 
possible that the disease is at present more frequent than formerly 
because of the more strenuous life and methods of education. The 
difference between "nervousness" and neurasthenia is only quantita- 
tive, and while nervousness is no disease in itself, it is also charac- 
terized by a short reaction time (irritability) and precipitate fatigue 
(weakness). 

Etiology. — Neurasthenia is the most common neurosis, constituting 
25 to 45 per cent, of all nervous diseases and fully 50 per cent, of all 
neuroses, (a) A neuropathic tendency is observed in 40 to 60 per 
cent, of cases, especially among Hebrews whose proneness to nervous 
diseases is referred by Erb to inbreeding and to desire of gain. Other 
neuroses, as hysteria, epilepsy or migraine, the psychoses, and parental 
infirmities or intoxications may be obtained in the family history. 
(b) Age and sex: It is a disease of adults (75 per cent, of cases occur 
in persons between the twentieth and fiftieth year). It is a question 
whether men are more often neurasthenic than women; we may say 
women are more disposed, men more exposed, to the disease, by their 
excesses in work, sexual activity and alcoholism, (c) Psychical 
causes include sorrow and care; hard mental or physical work rarely 
produces neurasthenia. Worry is a prolific factor; it is the irritable 
weakness of work. Hard work is injurious when combined with 
excesses in tobacco, alcohol, coffee, drugs or venery. Certain occu- 
pations entailing responsibility or emotional factors predispose to 
nervous weakness, as in railway or telegraph employes, board-of-trade 
men, teachers, actors, artists, and musicians, but even then it is ques- 
tionable whether the work itself is most injurious. Trauma operates 
chiefly through psychical causes, as in the traumatic neuroses (q. v.). 
(d) Intoxications, as from the stimulants above mentioned, from drug 
habits, lead or arsenic poisoning, acute infections, especially typhoid 
or grippe, from chronic affections, notably malaria and syphilis, and 
altered condition of the blood, as gout, anaemia or diabetes, may be 
indirect factors, (e) Sexual life: Masturbation, excessive coitus, and 
coitus interruptus, sometimes promote neurasthenia, but their impor- 



1194 DISEASES OF THE NERVOUS SYSTEM 

tance is enormously overestimated. Masturbation probably produces 
less direct physical than psychical injury, for it leads to brooding over 
its possible results. Continence is never injurious, as sexual indulgence 
is rather a habit than a necessity. In neurasthenic women gynecolog- 
ical complaints are more often subjective, secondary, and neurasthenic, 
than objective, primary and organic. The same statement usually 
holds true in male neurasthenics with chronic urethritis, or prostatitis. 
Pregnancy and lactation are sometimes apparent causes. (/) Organic 
diseases may possibly be factors, but it is questionable to what extent 
enteroptosis, chronic gastric or other somatic lesions promote neuras- 
thenic symptoms, (g) Climate: Neurasthenia is more common in 
northern climates with relatively high altitude than in southern zones. 
It is possible that alcoholism with nervous tension is more potent than 
either climate or altitude. 

Symptoms. — A clinical description holding for all cases is impos- 
sible. A patient presents himself for the treatment of some single vis- 
ceral complaint, or describes symptoms in his head, heart, lung, 
stomach, sexual or other organs. The various types, which are often 
separately described, will be considered in the general picture, for 
pure forms are rare; they are the cerebral (c erebr asthenia) , spinal 
(myelasthenia) , cerebrospinal (the general type), the sympathetic or 
vasomotor and the visceral (cardiac, sexual, gastric) types. Some 
varieties concern the course, as (a) the acute form from simple nervous 
exhaustion in normal individuals, or in those with neurotic stigmata; 
(b) the subacute or chronic acquired form, and (c) the chronic consti- 
tutional neurasthenia, which is usually hereditary. 

1. Cerebral Symptoms. — These are most important, because the 
disease is really a psychoneurosis. Headache is almost invariable, 
is more often dull than acute, and produces a sense of pressure ("lead 
cap " headache) or intracranial paresthesia, and in localization is most 
often occipital. Vertigo is frequent. Insomnia is extremely common, 
but rarely absolute which always suggests organic brain disease ; sleep 
is slow in onset, the patient being kept awake by his fear of sleepless- 
ness, by a rapidly moving circle of uncontrollable memory pictures or 
by indigestion or palpitation; sleep, when once attained, is not resting 
or is too short, and the patient awakes in the night or early morning. 
It is broken by dreams, startings or sometimes emissions. In mild 
cases distinct alterations in temperament and character develop, as 
loss of courage and confidence, depression, irritability, undue response 
to emotional stimulation, as on seeing sad plays or hearing hard-luck 
stories, slight ethical blunting, tendency towards extremes, and develop- 
ment of quiet self-concentration or obtrusive egotism. The brain 
tires readily on mental or bodily exertion, especially as the irritable 
patient is often prodigal of time and energy. It is remarkable how 
in some cases the morning depression may disappear before an after- 
noon or evening excitement, but this is notably followed by reaction. 
Psychical processes are disturbed; perception is blunted and memory 
is weakened or often temporarily lost (dys-, para-, amnesia), as 



NEURASTHENIA 1 195 

shown by the copious notes of his symptoms which the patient pro- 
duces in the physician's office (" V homme aux petits papiers," as Charcot 
called him); association and combination are difficult, as in thought, 
composition, judgment or conclusions, whence the speech is often slow 
and disjointed, names are forgotten and the patient re-reads addresses, 
runs repeatedly to see if the door was closed, etc. Compulsory con- 
ceptions may lead to homicide or suicide in highly psychopathic types. 
Fear, being an attribute of the weak, is common enough, and may in 
marked types assume the form of various phobias, as the fear of open 
places (agarophobia), of enclosures (claustrophobia), rivers (potomo- 
phobia), high places (acrophobia), stars (asterophobia), railways (sider- 
dromophobia), dirt (mysophobia), of high things falling (batophobia), 
of standing (stasophobia), or walking (basophobia), of darkness (nyc- 
tophobia), of a single thing (monophobia), of all things (pantophobia), 
of places (topophobia), of men (anthrophobia) or of disease (noso- 
phobia). The special senses are involved. Fibrillation of the lids, 
and wide, variable, sensitive and unequal (3 per cent.) pupils are fre- 
quent, although permanent irregularity almost always results from 
organic disease. Asthenopia is very common, especially in hyper- 
metropia from weakness of the ciliary and int. recti muscles. The 
field of vision may be concentrically limited but this is rarely marked 
or permanent, and Foerster's shifting type may be found, in which 
objects brought from without into the field are better seen than those 
moved from within the field outward. Hyperesthesia of the retina 
and ear, ringing in the ears, Meniere's complex, and disturbance of 
taste or smell are not common. 

2. Spinal Symptoms. — These include the so-called "spinal irrita- 
tion." Many symptoms ranked as spinal are essentially cerebral. 
In women they are more common and are localized chiefly to the upper 
dorsal and coccygeal regions; in men they are lumbodorsal and most 
frequent in the sexual type. Sensory symptoms are practically con- 
stant. Hyperesthesia is more common in the bodies of the muscles 
than in their attachments or in the skin; paresthesia is frequent, as 
tinglings, girdle sensation or even a sense of itching. Paralgesia in the 
form of backache (rhachialgia) is as frequent as headache and the pain 
may radiate into the various nerve plexuses ; it is very often sacral ; the 
spine may be exquisitely sensitive to pressure. Paralgesia is common in 
the skin about the hair roots, in the trunk and extremities. Neuralgia is 
rare, although it sometimes occurs as a form radiating from the spine 
into the limbs. Anesthesia is no part of neurasthenia. Of the motor 
symptoms, muscular weakness, or myasthenia, is the rule. It is prob- 
ably spinal and cortical in origin and is especially conspicuous in the 
morning. The muscles often show fibrillary contractions and a tremor 
(85 per cent.) which is as fine and frequent as that of alcoholism or 
Graves' disease. Muscular fidgets, starts, cramps and increased irrita- 
bility of the nerve trunks, as in tetany, are also observed. Actual 
ataxia is most rare, although suggested by the writing. The akinesia 
algera (Mobius) or the abasia-astasia of Blocq, as in hysteria or the 



1196 DISEASES OF THE NERVOUS SYSTEM 

psychoses, is the result of a phobia or a fixed conception. One of 
Erb's patients remained in bed for fourteen years. The skin, tendon 
and periosteal reflexes are increased. 

3. Vasomotor Symptoms. — These produce many central, visceral 
and peripheral manifestations. It has been proved by Mosso that 
during brain-work the cerebral vessels normally dilate while those of 
the arm contract. According to Anjel this does not occur in neuras- 
thenia. The manometer in normal cases reveals no essential variation 
during work, while in neurasthenia marked manometric variations 
occur, as also shown by Weber by the sphygmograph. These findings 
furnish some diagnostic and prognostic aid, for their intensity parallels 
the prognosis, but they are especially valuable because they explain 
many otherwise vague findings. Neurasthenics often suffer from 
cold, and wear more clothes than is necessary; their skin is cold, even 
cyanotic or locally asphyxiated. On the other hand, the skin may be 
flushed and hot. Cold and clammy sweats over the forehead, hands 
and feet, develop without exertion. Salivation or a dry mouth, 
polyuria, pseudo-angina pectoris (vasomotor changes in the cardiac 
and brachial plexuses), the wide temporal vessels, the epigastric pul- 
sation, circumscribed oedema, urticaria, and dermographism are but 
vasomotor manifestations. 

4. Visceral Manifestations. — (a) Some of the cardiovascular sigias 
and symptoms have already been treated. The arteries are relaxed 
and often throb, the pulse may be slightly of the " water-hammer" type 
and capillary pulsation is often apparent in the lips or under the nails. 
Palpitation and precordial anxiety or dyspncea are frequent. The pulse 
is frequently faster and may increase 10 or 20 beats on pressure over 
some sensitive area (v. i. Traumatic Neuroses). Many neurasthenics 
seek consultation for cardiac disease. (b) Gastric symptoms (in 50 
to 66 per cent.) are functional in character, and were first described by 
Leube. The chemism may be normal or show either achlorhydria, or 
hyperchlorhydria. The stomach is frequently hypersesthetic. Anorexia 
is usually mental, as are polyphagia, polydipsia and adipsia (see 
Neuroses of Stomach), (c) Intestinal symptoms may develop. Diar- 
rhoea is less common than constipation, which, like previous sexual 
abuses, often occupies the patient's thoughts. They "would be per- 
fectly well if they could only have one natural movement," and when 
they do, they complain of "exhaustion during the entire day after- 
ward." Assimilation is often incomplete, as shown by the stools; a 
sense of pressure, KussmauTs peristaltic unrest, hyperesthesia, burn- 
ing and flatulency torment the patient. Enteritis membranacea and 
Glenard's enteroptosis are not infrequent, id) The amount of the 
urine is often increased, or seemingly so, yet equally often the 24-hour 
quantity is decreased. The specific gravity is lowered, but the urates, 
uric acid and urea are increased. Phosphaturia and oxaluria occur; 
the latter is often attended by flatulent dyspepsia, melancholia and 
nervous depression. Indicanuria is not constant, and glycosuria and 
albuminuria are accidental. Vesical tenesmus is an occasional com- 



NEURASTHENIA 1197 

plaint, (e) Genital symptoms may be marked. Fear of the results of 
previous excesses or of self-abuse may dominate the patient's mind, but 
the trouble is more a matter of conception than of reality, since the 
sexual appetite is actually decreased as a rule. In most cases there is 
premature ejaculation and in some patients there is actual or psychical 
impotence. Emissions are frequent, but their importance is greatly 
overestimated. 

Course and Prognosis. — Acute cases are rare and fatal cases extremely 
exceptional. The usual chronic course is one of slow onset, it is 
attended by evidences of nervous fatigue which are at first relieved by 
rest, but which later persist in spite of rest and incline the patient to 
stimulants or drug habits. Later the signs of cerebral irritability, dis- 
turbed sleep, vasomotor disorders, reduced mental and psychical 
capacity, pains, spinal tenderness, paresthesia or paralgesia, sym- 
pathetic dyspnoea or palpitation develop, sometimes with temporary 
remissions. The outlook is poor in severe hereditary forms, or when 
there are complicating psychoses or drug habits. In other types 
recovery is usual, although it is generally long deferred. Complication 
with hysteria, epilepsy, migraine, and other neuroses must naturally 
modify the prognosis. 

Diagnosis. — The diagnosis is generally made with ease, but several 
rules must be borne in mind : (1) No single symptom is pathognomonic; 
(2) there must be no sign of organic disease; (3) neurasthenia may pre- 
cede, follow or complicate organic nervous or visceral disease. The 
subjective signs, irritable weakness, emotivity, muscular weakness, 
headache, backache, insomnia, amnesia, impaired psychical coordina- 
tion, and the phobias, together with objective findings, as asthenopia, 
insufficiency of the internal recti, tachycardia, epigastric pulsation, 
vasomotor alteration, as disturbed secretion of urine or sweat, increased 
reflexes, fibrillation and tender muscles cannot be mistaken. The 
neurasthenic prodromes of progressive paralysis, (q. v.) are usually 
distinguished on careful search for organic disease. Hysteria in its 
stigmata and accidents is so typical that elaborate differentiation is 
superfluous; anaesthesia, persistent contraction of the fields of vision, 
dyschromatopsia, achromatopsia, monocular diplopia, convulsions, par- 
alyses, contractures and anuria are foreign to neurasthenia. Hypo- 
chondriasis differs from neurasthenia in these essential points : it is a 
pure psychosis, its concepts are primary, they are ill-based, illogical 
or absurd and cannot be eradicated even for a time. 

Treatment. — Prophylaxis. — Prevention is difficult, for the neuras- 
thenic cannot control his ancestry, but even with hereditary stigmata 
much may be done. Treatment starts with the education of both child 
and adult. Children are mimics and the clearest of all observers. The 
inculcation of self-control, fearlessness, self-sacrifice, moderation in all 
things, truthfulness, prompt decision and constancy of purpose must be 
based on actual parental example, and in this way the child should also 
educate the parent. The child must learn to give up, to sleep alone, 
to stop at the right time, to finish what he has begun, to obey, and to 



1198 DISEASES OF THE NERVOUS SYSTEM 

learn that he is not the centre of the family. He should be taught 
without being forced. Out-door living is more important than the 
school room. The English method of treating children with reserve 
has some advantages over American demonstrativeness. Simple 
varied food, without tea, coffee or alcohol, and long sleeps develop a 
strong nervous system. The sexual instinct requires attention. Parents 
or patients would do well to read Patrick's small classic, "How Not To 
Be Nervous"; Jour. Amer. Med. Assn., Feb., 1903. 

Therapy. — When once manifested, the disease should be treated 
as above outlined and causal factors should be investigated. Work 
alone is seldom injurious, and while it is said that the modern com- 
plexity in the struggle for existence is increasing the number of neuras- 
thenics, work should not bear the stigma nor should disappointment, 
for both make character. Work must be systematic but not slavish. 
Worry, hurry, failure to learn individual limitations, uncontrolled 
planning beyond the immediate day's work, and worry (the irritable 
weakness of work) cause the damage, especially when work produces 
some indifference to nature, family life, exercise, rest, and the things 
higher and above one's own small life and ambition. The time for 
exercise should be taken from the work hours, it should not follow 
them, nor should it be enforced in every case, for some people are hurt 
by it. Of course, work under stimulation is injurious. It is held that 
the chief element in treatment is psychical and surely the physician 
accomplishes more than do drugs. He carefully examines and re- 
examines the patient, and his assurance that no organic disease exists, 
has its weight for the time. Conversely, careless diagnoses, as of fatty 
heart, with no objective justification, work damage to the patient's 
mental balance. The patient's hygiene should be regulated. Strict 
dietaries and stimulants should be avoided, moderate out-of-door life 
or exercise enjoined, and in very pronounced cases absolute rest from 
work, with sojourn near the sea or at a moderate altitude in a place 
not subject to sudden changes or high winds, is recommended. Sexual 
matters should be left alone unless gross violations are found. The 
patients need sympathy, which they should receive — in moderation for 
their sake, and lest the physician become "touched" with neuras- 
thenia; but important as is the psychical element in therapy, the 
patient must be taught that he alone can cure his malady by self- 
control, and by avoiding extremes in each and every thing. 

Pronounced cases in thin women, especially those with gastric 
symptoms, are often helped by the Wier Mitchell rest-cure, which con- 
sists of absolute rest in bed, isolation, forced feeding, massage and 
faradization. The patient is not allowed to lift a hand, and sees only 
the nurse, who is selected for her strength, optimism and lack of nerves. 
The patient is fed milk every two or three hours, and the muscles are 
rubbed and faradized. Thus weight and strength are gained without 
muscular degeneration. Few men will tolerate this method, and obese 
do not fare as well as lean women. In certain cases it is of distinct 



THE " TRAUMATIC NEUROSES" 1199 

benefit. However, no greater mistake is made than to give all cases the 
rest-cure; they often want work and occupation, harmonized with 
rest. 

Diet. — That no one dietary is essential is shown by the different 
recommendations; some physicians favor a meat diet, others avoid 
meat, especially in cardiac types, and give well-cooked vegetable albu- 
mins, cooked fruit, fats, milk and eggs. In mental anorexia, feeding 
by mouth or rectum must be forced. Water in abundance is indicated. 
Gastric hyperesthesia should be relieved by small doses of carbolic 
acid and gelsemium. Eructations must be controlled, since the air 
admitted exceeds the gas expelled; asafcetida is excellent because it 
makes as strong an impression when swallowed as when eructed. 
Electricity in general is largely suggestive in its effects; cerebral gal- 
vanization gives uncertain results. With massage and vegetable diet, 
endorectal faradization relieves constipation. In cardiac types alcohol 
and tobacco are interdicted, and small doses of belladonna and bromide 
usually control palpitation; other vasomotor symptoms are relieved 
by these remedies, or by ergotin or nitroglycerine, according as they are 
angioparetic or angiospastic. Arsenic is valuable in vasomotor 
troubles with anaemia. 

Sexual symptoms are treated by psychical measures and by sitz- 
baths. Insomnia is often difficult to relieve. In the order named, the 
following measures are valuable: avoidance of evening work, stimu- 
lants or excitement; a cool bath, the wet pack or an ice-bag over the 
heart; small doses of bromide with valerian for the "expectant at- 
tention" which wards off sleep; 20 grains of sulphonal in hot milk, 
which should be slowly sipped; codeine with hyoscine; and chloral 
(the continued use of which induces vasomotor disturbance). The 
habit of sleep is like the habit of insomnia; it must be cultivated, and 
the patient must not get up to read. Local, urethral, and uterine 
affections usually receive excessive therapeutic attention. 



THE "TRAUMATIC NEUROSES." 

This is a practical grouping of traumatic neurasthenia, hysteria, 
chorea or hypochondriasis. Hysterical forms were first described by 
Walton and Putnam, Erichsen (1866) wrote on the subject of trauma to 
the spine, on which the illogical name of railway spine was later conferred, 
and Oppenheim (1887) termed the group the "traumatic neuroses." 
All organic affections must be excluded, whether trauma may seem 
directly or indirectly causal, as vertebral caries, tumor, Bechterew's 
chronic ankylosis, Kummel's rarefying osteitis which Kocher refers to 
fracture; hsematorrhachis, meningeal hematoma, or pachymeningitis; 
ami cord affections, as poliomyelitis, myelitis, or lateral sclerosis. Experi- 
mental trauma may produce molecular nervous changes (Schmauss, 
Striimpell, Bruns, Vibert and Crocq), a fact which may be of clinical 
importance, and trauma is thought to hasten arteriosclerosis (Fried- 



1200 DISEASES OF THE XERVOUS SYSTEM 

mann). Alcoholism and syphilis are predisposing factors. " Traumatic 
neuroses" are purely functional affections caused by trauma, which 
operates psychically rather than somatically. The symptoms are those 
of hysteria, neurasthenia, and hypochondriasis, singly or in combination. 
The patient may feel well for a day or two and then pain develops at the 
seat of injury or in the spine; anxiety, fear for his financial future, or 
for his family, a "fixed idea" of his incapacity, and the development of 
"litigation symptoms" are typical of hypochondriacal neurasthenia. 
The psychical symptoms are usually but not always prominent; 
they are accentuated by the effect on the patient of repeated, sometimes 
suggestive, physical examinations, visits of lawyers or adjustors, court 
room suspense, reversals of judgment or appeals. Vertigo, backache, 
headache, sleepiness by day, and nocturnal insomnia may cause great 
distress. Sensory symptoms may be present. Pain, which seems to be 
nervous, may prove organic on examination by the x-rays; it may be 
simulated, but is often real, as shown by persistence after award of 
damages. Tender areas are difficult to pass upon, because of exagger- 
ation or simulation; Mann, Kopf and Rumpf found that pressure on 
areas which are actually tender increases the pulse rate by 10 to 30 
beats; this sign is subject to several conditions: (a) it is not always 
present in real pain; (b) its absence is no proof of simulation; (c) in 
simulation, the agony and writhing which occur when certain areas are 
touched may increase the heart's action. Paresthesia and hyperes- 
thesia of the skin or special senses are frequent. Anesthesia indicates 
traumatic hysteria. Hysteric or neurasthenic contraction of the visual 
fields may remain the same from day to day, and not vary with ap- 
proach or withdrawal of the test object; this is not a sign of simulation 
as suggested by some writers; Forster's type (v. Neurasthenia) can- 
not be assumed. In all cases the influence of suggestion must be borne 
in mind. The pupils may vary, especially by dull illumination; reflex 
immobility indicates organic disease. Motor symptoms may embrace 
all those of hysteria or neurasthenia, abasia, astasia, paralyses, con- 
tractures suggesting vertebral injury (Kummers rarefying osteitis) or 
joint disease (Brodie's joints), pseudo-spastic or -tabetic gaits, tremor 
(forme trepidante), or sometimes muscular atrophy (especially about the 
joints). Hysterical convulsions are rare; the author has twice seen 
choreiform affections in telephone girls, who sustained slight shocks 
and once a genuine chorea. Patients must often be watched; one of 
the author's cases, with spastic gait, shuffled out of the office, but 
walked perfectly well around the corner. The reflexes are often in- 
creased, perhaps asymmetrically; ankle clonus, which is probably 
spurious, is sometimes reported. Cardiac symptoms may be prominent 
and cannot be simulated. When there is albuminuria and glycosuria, 
the question naturally arises whether they were present before the 
trauma. 

Diagnosis. — The diagnosis concerns several points which are often 
difficult or impossible to establish, because objective findings are fre- 
quently few. (a) It is usually possible to state whether one of the 



EPILEPSY 1201 

neuroses is present or whether organic disease obtains, (b) Exagger- 
ation and simulation are difficult to estimate, as shown by the change of 
professional opinion from the idea that all or most cases are simulated 
to the present statement of some writers that these factors are present 
in 4 (to 10) per cent, of cases only, (c) If disease is present, is it di- 
rectly due to injury ? (d) If so, the most difficult of all questions is 
presented, namely, the degree and duration of the disease, and the 
damages to be awarded. 

Prognosis. — (a) As to life, the outlook is usually good, though some 
cases become insane or suicidal, (b) As to complete recovery, it is less 
favorable. In most cases it is surprising how soon symptoms disappear 
after satisfactory legal settlement is made ; this is said without cynicism. 
Many persons do not then recover completely and symptoms may 
endure in those who persistently shrink from litigation. Hysterical 
symptoms are more favorable in prognosis than the neurasthenic or 
hypochondriacal. It is maintained by some that cardiac overaction 
may induce organic myocardial changes, and that arteriosclerosis 
may develop into precocious senility (dementia prsecox). 

Treatment. — Treatment is similar to that of hysteria or neurasthenia 
and is therefore largely psychical. The physician, as a rule, dreads the 
effect of litigation on the patient, assures him that the symptoms are 
seldom severe or enduring, that there is no organic lesion, and advises 
early settlement and speedy return to work. 



EPILEPSY. 

Definition. — Epilepsy, by derivation, means "being seized upon"; 
it has been called the " falling sickness," and morbus sacer. It does 
not mclude Jacksonian or symptomatic epilepsies, which will be con- 
sidered in its differentiation. Though it is classified with hysteria and 
neurasthenia as one of the "three great diffuse neuroses," it will pro- 
bably be finally shown to include more than one disease. It is a dis- 
turbance of balance between the central exciting and inhibiting nervous 
processes attended by (a) a typical chronic convulsive disorder, affecting 
all parts of the central nervous system, each attack being followed by 
loss of consciousness, (b) partial or atypical manifestations of these 
characteristics, or (c) concomitant or consecutive psychical or other 
symptoms. It occurs in from one to six persons per thousand. 

Etiology. — The ultimate causes must be separated from the inciting 
causes (Nothnagel). Of the former, the neuro- or psychopathic 
tendency of Griesinger is the most important, being found in 35 to 50 
per cent, of cases and causing lessening of the nervous resistance. As 
in tuberculosis, only the tendency is transmitted by inheritance, rarely 
the disease itself. Neurotic or psychopathic antecedents, parental 
alcoholism (51 per cent.), morphinism, plumbism, syphilis, tubercu- 
losis, gout, arthritism, diabetes, or ovarian and testicular disease, 
lessen the nervous resistance of the offspring. Trauma during labor 

76 



1202 DISEASES OF THE XERVOUS SYSTEM 

may be included under this head. Though the disease may appear at 
any age, it rarely occurs after the thirtieth year. Seventy-five per cent, 
of cases (Gowers) develop before twenty; 46 per cent, between ten 
and twenty, mostly at puberty; 28 per cent, before ten. The sexes 
are about equally affected. 

Inciting causes include (a) infections as malaria or typhoid; syph- 
ilis may be hereditary, induce malnutrition in the secondary stage, 
of the Jacksonian type from cortical gumma, or it may be parasyphi- 
litis; (b) intoxications, especially alcoholism; (c) exhausting affections 
as rickets, and diseases of the blood or of metabolism; and (d) trauma 
or fright. Inciting causes are found in only 37 per cent, of cases 
(Gowers). 

Reflex epilepsy is said to occur from painful scars, nerve tumors, or 
foreign bodies in the ear, nose, nasopharynx or larynx; from diseases 
of the teeth, digestive tract, uterus, and heart; from onset of the menses 
or their monthly appearance, pregnancy, phimosis, or onanism; from 
gall-stones, colic or abdominal paracentesis. While these factors may 
appear in certain cases and attention must be given to the general 
examination and health, the importance per se of reflex disturbances 
is daily lessening. 

Pathology. — The fact that there is no characteristic macro- or 
microscopic change is not proof that some cortical change will not 
later be demonstrated. The usual finding after death from an attack 
is that of any convulsion, viz., venous engorgement and punctate 
ecchymoses. Induration of the cornu ammonis (Meynert) (3 to 38 
per cent.), induration in the medulla, neurogliar increase in the cortex, 
thickening, asymmetry or deformity of the skull, or persistence of the 
thymus, have not yet been proven to exist constantly in epilepsy, nor 
are they proven causal. 

Symptoms. — The symptoms are best studied from the completely 
developed attack, in which there are three component parts: (a) The 
prodromal stage is not always present. Its " warnings " are either distant 
or immediate. The distant warnings (in 4 to 17 per cent, of cases) 
may precede the seizure by hours or days, are possibly due to metabolic 
changes in the cortex, and take the form of restlessness, dispositional 
changes, depression, thoracic or cephalic oppression, insomnia, 
vertigo, nausea, grinding of the teeth, hyperesthesia of the special 
senses, angioneurotic palpitation, or cerebral congestion. The im- 
mediate warning is the aura proper, which is the beginning of the 
convulsion rather than a warning. It is a central cortical irritation; 
its frequency ranges between 30 and 50 per cent. ; it is rarer in sudden, 
stormy, generalized seizures. Its forms are varied. The psychical 
aura is rare, and is manifested by emotional or intellectual alteration 
and anxiety. The sensory aura consists of paresthesia, and a sense of 
deadness in a limb or joint, attacks of migraine, and epigastric sensa- 
tions (from the pneumogastric nerve, pressure or irritation of which 
sometimes inhibits the convulsion). The special senses may be irritated 
or blunted; for instance, there may be flashes of light or colors, 



EPILEPSY 1203 

hallucinations, blackness before the eyes, and less often anomalies of 
hearing, taste or smell. The motor aurse are circumscribed clonic or 
much less often tonic twitchings, as in the signals of Jacksonian 
epilepsy, from which they are distinguished by a rapid loss of con- 
sciousness; automatic movements, like stamping, or buttoning the 
coat, are rarer, and motor weakness and singultus, coughing or sneezing 
are least frequent. Vasomotor auras may be localized or generalized, 
as rushing of blood to the head, palpitation, anaesthesia, increased 
temperature, increased arterial tension, pallor or chilling. The patient 
then falls, pale and unconscious, or is thrown with force, often on his 
face (Trousseau), when (b) the convulsive stage begins. There is first 
a tonic convulsion, which affects all voluntary muscles, and is due to infra- 
cortical irritation. The initial cry is gutteral or groaning, results from 
tonic abdominal, thoracic and laryngeal spasm and is heard in 50 per 
cent, of cases. The head is held back; the eyes are open and staring, 
the jaw set, the face flushed, the neck tense, the body usually opistho- 
tonic, breathing is suspended, the muscles are hard but slightly 
vibrating to the palpating hand, the arms are turned tetanically inward, 
the hands are clenched with the thumb adducted and under the fingers, 
the legs are extended, the thighs adducted and the toes flexed or 
extended and spread apart. In some cases the head, eyes or even trunk 
deviate, and in a few instances the tetanic spasm spreads gradually, 
instead of the patient having the usual instantaneous tonic spasm. 
The tonic phase lasts ten, fifteen or thirty seconds, relaxing in inverse 
order from the limbs to the neck and face. The second phase of clonic 
convulsion occurs at once, appearing first in the limbs, which are not 
yet quite free of the tonic spasm. This stage is usually bilateral, 
highly irregular and violent, with very short remissions, leading 
perhaps to injury, fracture, luxation, breaking of teeth, laceration of 
skin, tongue and cheek, or rupture of muscles. It consists largely of 
alternating flexion and extension; the head strikes the ground, the 
body turns violently, the eyes jerk and protrude, the face is distorted, 
the tongue is bitten as it is thrust out, bloody saliva is expressed by the 
masseters, inarticulate sounds arise from the movements of the dia- 
phragm and respiratory muscles, and gurgling results from intestinal 
movements; vomiting movements, filling of the stomach with air, 
cyanosis, swelling of the jugular veins, ecchymoses in the conjunctiva, 
skin, retina or larynx, involuntary and sometimes forcible evacuation 
of the bladder, less often of the rectum, and occasionally ejaculation, 
occur. The clonic phase lasts one-half to three minutes, ending in a 
fine generalized tremor, (c) The comatose stage often begins with a 
deep sigh; respiration and circulation become normal, the limbs relax 
and the condition resembles a sound sleep, from which the patient 
awakes in from fifteen minutes to several hours, sometimes suddenly, 
more often gradually, and in a more or less dazed condition. He 
recalls nothing of the attack and the loss of memory may extend back 
of the seizure (retrograde amnesia). He experiences pain in the 
muscles, joints or head, nausea, mental irritability or depression and 



1204 DISEASES OF THE NERVOUS SYSTEM 

finally a group of exhaustion symptoms, to which Fere has especially 
directed attention; these are (i) sensory exhaustion, expressed by 
hypsesthesia, anaesthesia, hypalgesia or analgesia, (ii) Exhaustion 
of the special senses, as concentric limitation of the visual and color 
fields, especially in abortive attacks, dulling of hearing, taste or smell, 
and (hi) motor exhaustion which, like (i) and (ii), is due to cortical 
fatigue. The reflexes are often weak or abolished. 

The seizure has been described with special reference to the dominant 
motor changes, but during the attack other findings are observed. 
Vasomotor constriction often occurs, as shown by the initial pallor of 
the face, cardiac overaction or perhaps irregularity. The ecchymoses 
and retinal congestion are probably due to the convulsion. The 
reflexes are affected. The pupil is almost always reactionless, is often 
narrow at the onset, and usually dilates widely in the second stage; 
afterwards it may oscillate; the pupils are sometimes unequal (20 
per cent., Fere). The tendon and skin reflexes are weak or lost in 
complete attacks and for hours afterwards, whence we may judge of 
the severity of the seizures. The temperature is usually considered 
normal, but may be elevated 2 or 3°. In the urine, Voisin found 
albumin in 50 per cent., though others consider it infrequent. The 
author has often noted transient albuminuria and cylindruria (granular 
casts) after marked paroxysms; glycosuria is uncommon. The toxicity 
of the urine, the phosphates and the nitrogen are increased; polyuria is 
common in the third stage. The sweat is increased. 

Types of Epilepsy. — 1. The completely developed attack (epilepsia 
gravior, haut or grand mal) consists of (a) the classic type (29 per cent.), 
as above described, with complete loss of consciousness, and tonic 
followed by clonic convulsions; or (b) the well developed but slightly 
atypical type (19 per cent.), in which all the components of (a) are 
present but vary somewhat; for instance, the spasm may not always 
be generalized. 

2. The rudimentary attack (21 per cent.), consists of loss of con- 
sciousness, plus tonic or clonic spasms, but not both. This includes 
the apoplectiform cases, especially the senile (arteriosclerotic) form; 
the forms resembling myoclonus; the cases which do not fall but 
stumble along at the onset (epilepsia procursiva) or turn (epilepsia 
rotatoria). 

3. The third form is the abortive attach (epilepsia mitior, petit mal> 
31 per cent.). Its importance is underestimated by the profession 
and the public; two main types, with endless variations are distin- 
guished: (a) one with loss of consciousness with few or no motor 
signs, and (b) motor and vasomotor signs with no loss of conscious- 
ness, or very slight clouding of the intellect. The loss of conscious- 
ness is often very slight, or may last for a few seconds, so that a 
scarcely perceptible break occurs in the patient's occupation, read- 
ing, speaking, playing the piano or a game of cards ; it is described by 
the French as "absence." He may move his lips inarticulately or 
there is slight nystagmus, a chewing or swallowing movement, tremor 



EPILEPSY 1205 

or twitching of the face, monospasm, or vertigo. In children, a cry 
may be the sole symptom. Some patients seem to fall suddenly asleep. 
Nothing, or everything, may be remembered. Aura? are very common 
and may constitute the whole attack, which aborts without loss of 
consciousness or spasms. Vasomotor symptoms are very common. 
Some would include the rudimentary type under this head. 

4. The psychical equivalent of Sammt, which is also known as trans- 
formed or larvated epilepsy or the epileptoid condition (Griesinger), 
is often mistaken. Mental symptoms may precede, succeed, alternate 
with or replace the ordinary convulsive type, which must be first 
recognized to establish this variety. The mental changes are slight 
(petit mat intellectuel) or marked (grand mal intellectuel) and include 
excitement, emotional outbursts, narcolepsy, incoherent conceptions, 
amnestic attacks or even mania. The patient may act like an hypno- 
tized subject; he may take sudden long journeys, or commit assault, 
arson or murder, whence the great medico-legal significance of this 
variety. Milder forms are said to occur, as sweats, stupor or vacuity 
at the menstrual epoch. 

The Interparoxysmal State. — If the patient is not to be seen during 
his seizures, evidences of epilepsy should be looked for carefully. Signs 
of psychical degeneration, poor differentiation of the ear, very large, 
small or prominent ears, hsematoma of the ear, deformed teeth, lips 
or palate, coloboma, congenital strabismus, nystagmus, small eyes, 
irregular pigmentation of the iris, deformed genitals or fingers, dis- 
orders of speech or irregular facial innervation may indicate heredi- 
tary taint. Neurasthenic symptoms are not unusual. The expression 
is often dull. When idiocy occurs with epilepsy there are two possi- 
bilities; first, that both are coordinate results of a common cause, or 
second, that early, chronic and repeated attacks have initiated mental 
degeneration. However, many brilliant men have been epileptics, 
as Julius Caesar, Napoleon, Carl V, Peter the Great, St. Paul, Mo- 
hamed, Petrarch and Rousseau. The importance of organic disease 
of the heart, lungs, stomach, and kidney, is difficult to estimate. It is 
possible that the future study of metabolism may establish the autc*- 
intoxication theory. Epileptics often sweat profusely, are usually 
constipated and frequently become obese from inordinate eating and 
from the bromide treatment. 

Diagnosis. — The diagnosis concerns the convulsive seizures and 
the abortive types. Similar convulsions occur in numerous other con- 
ditions and must first be excluded. They occur in (a) organic brain 
disease, as syphilis, tumors, vascular lesions, paretic dementia, multiple 
sclerosis, and infantile cerebral paralysis. These affections may 
produce generalized or Jacksonian fits. Jacksonian epilepsy is more 
clonic (from cortical irritation) than tonic (due to infracortical irrita- 
tion), is often associated with paresis or sensory alteration, occurs less 
often with coma unless its generalization is unusually wide, and in 50 per 
cent, of cases is due to small cortical tumors. Epilepsy rarely (E. 
tarda) develops after thirty years of age, and 90 per cent, of cases which 



1206 



DISEASES OF THE NERVOUS SYSTEM 



occur after thirty, — excluding alcoholism and uraemia, — are syphilitic 
(Fournier, H. C. Wood). After forty-five, vascular lesions are a very 
common cause. In some cases true epilepsy appears to follow the 
Jacksonian type, (b) Convulsions may occur in altered conditions of 
the blood, as alcoholism, urcemia (eclampsia), plumbism or drug 
poisonings, (c) Reflex epilepsy results from dentition, worms, or 
digestive disorders; in some cases genuine epilepsy seems to follow 
the reflex form (which perhaps is epilepsy in itself). 

Simulation of epilepsy is impossible. In the complete type, the 
tongue biting, cry, stertor or involuntaries may be absent. Scars are 
often of diagnostic value. Nocturnal epilepsy occurs in 33 per cent., 
often coming on when the patient drops off to sleep or on awakening 
in the morning; it easily escapes recognition for years, but the de- 
pression, bitten tongue, ecchymoses and involuntary evacuations are 
unmistakable. 

Differentiation from hysteria, which is usually easy, may be difficult, 
indeed the two affections sometimes co-exist; the following table is 
combined from Gowers and Biswanger: 



Epilepsy . 1 

Distant warnings: few, mental. 
Aura: more frequent, momentary, 
oftenest unilateral or epigastric. 

Cause: none. 

Onset: always sudden, often with pallor, 
cry which is never verbal, immediate 
falling and complete unconsciousness, 
with rigidity, etc. 



Tongue biting, frothing: very common. 

Convulsions: generalized, tonic followed 
. by clonic spasms, very rarely tonic 
p alone; flexor spasm predominates. 



Reflexes: pupils contracted at onset, 
dilated later, immobile (in clonic 
period). Tendon and skin reflexes 
absent during and after attack. 

Involuntary evacuations: frequent. 

The urine: solids always increased, 
both nitrogen and phosphates. 

Temperature: sometimes elevated.. 2-3°. 

Coma: complete. 

Duration of seizure : very short. 

Post-paroxysmal: sensory and motor ex- 
haustion, ecchymoses, absent reflexes, 
mental incapacity, with no memory 
of transpired events. 



Hysteria. 

Frequent, emotional. 
Less frequent, longer, bilateral foot 
aura, globus. 

Emotional. 

More gradual, rarely with pallor or cry, 
which may be repeated or verbal, and 
recurs later. Rarely brusque falling, 
slower and far less complete uncon- 
sciousness, and may react to sugges- 
tion or pressure on hysterogenous 
zones. 

Exceptional, or seemingly purposive. 

Rigidity, to carry out semi-intentional 
movement; struggling; clonic, irreg- 
ular spasms, seemingly fragments of 
partial movements of emotion; ex- 
tensor spasm predominant "arc de 
cercle," clownism, passional attitudes, 
etc. 

Pupils usually wide and react (may 
be immobile, Westphal, Karplus). 
Sometimes convergent strabismus. 
Reflexes not absent or increased. 

Absent or most exceptional. 

All solids decreased and altered ratio 
between earthy and alkaline phos- 
phates. 

Practically never. 

No real coma. 

Longer, recurrent, relapsing. 

Depression, fatigue, pain in head or 
stomach, nausea, some memory of 
attack 



EPILEPSY 1207 

The most difficult forms to differentiate are petit mal and trans- 
formed epilepsy, in which the history or observation of major attacks 
is important. Petit mal may be confused with cardiac syncope, 
labyrinthine vertigo, etc. 

Course and Prognosis. — When one attack has occurred, a second 
may be expected in 33 per cent, of cases in less than one month, in 
33 per cent, in from one to twelve months, in 33 per cent, in over one 
year; and when epilepsy is once established, daily attacks occur in 10 
per cent., in 50 per cent, they occur at intervals of less than two weeks, 
and in 75 per cent, they occur at intervals of less than one month 
(Gowers). The mode of life, stimulation, excitement, pregnancy, and 
sexual excesses may increase their frequency, and cessation during 
fevers is not uncommon. In some, though fortunately rare, cases, the 
attacks occur in quick succession (status epilepticus, etat de mal), as 
many as 10 or 30 or over 100 occurring in one day. In one case 2,500 
seizures occurred during a month; the stage of coma may last from 
two or three days to a week, with a temperature of 105-7° and death 
then results. The outlook (a) as to recovery is poor. Five to 10 per 
cent, of cases may recover spontaneously (Huf eland, Dana, Miiller). 
The prospects are best in cases which begin before twenty, in males, in 
cases with long intervals, and, though it may seem strange, in hereditary 
forms. After two years' duration, the outlook is unfavorable. (6) 
As to life, the prognosis is more favorable. A few cases drown, suffo- 
cate from turning on the face, or are fatally burned during the seizure. 
Some patients die during the insult from vascular lesions of the brain, 
or less often from heart rupture, respiratory cramp, oedema of the 
lungs or vomiting into the larynx. The status epilepticus and delirium 
tremens are dangerous. Epileptics frequently become tuberculous. In 
10 per cent, dementia occurs. The average duration of life is probably 
shorter than normal. Bodily health and intellectual vigor may, how- 
ever, be remarkably preserved. 

Treatment. — 1. Treatment of Cause. — This has a limited scope. 
Syphilitic epilepsy, unless due to a gumma or to the secondary ansemia, 
does not respond to antisyphilitic remedies. Avoidance of alcohol 
may be almost curative in this form. Reflex factors should be removed. 
In Sweden epileptics cannot marry; 50 per cent, of hereditary epileptics 
transmit some transformation of the taint to their offspring. 

2. Hygienic Therapy. — New cases in children should receive the 
general care outlined under the other neuroses. Work in school should 
be limited to a few hours, and country life is generally preferable to 
that in the city. For very poor subjects, institutional treatment is 
indicated. Erb uses galvanization through the head. Most neurolo- 
gists greatly restrict the consumption of meat, although Gowers allows 
it once or twice a day. Toulouse and Richet withdraw salt, and give 
a milk and cereal diet, which they think promotes the affinity of the 
bromides for the brain cells. 

3. Bromide Treatment. — This was introduced by Laycock (1853), 
and was developed by Voisin. The bromides act directly on the 



1208 DISEASES OF THE XERYOUS SYSTEM 

nervous tissue; they depress the cortical cells, with which they organ- 
ically unite, inhibit reflex action in the brain and cord, and lessen 
centripetal conduction. Untoward symptoms may result even within 
therapeutic limits. Intellection may be dulled and muscular depres- 
sion occur, but these may often be counteracted by administration 
of coffee; the frequent stomach symptoms can be avoided by free 
dilution of the bromide in water; diarrhoea, which results especially 
from potassium bromide, is relieved by opium if marked, or if less, by 
salicylate of bismuth and beta-naphthol, aa gr. x, after meals; in its 
elimination by the skin, acne is common, which is lessened or removed 
by giving large quantities of water and small doses of arsenic, and by 
washing the skin with green soap. Belladonna in small doses will 
modify the respiratory catarrh or salivation. The anaphrodisiac 
effects cannot be prevented. In some individuals there are marked 
idiosyncrasies , as mental excitement, hallucinations, rapid emaciation 
("bromide cachexia") with lessened physiological resistance to acute 
diseases. Toxic symptoms may be acute, resembling those of paretic 
dementia, but more commonly are chronic; chronic bromism is most 
likely to develop in those with weak digestion or circulation and when 
the drug is given carelessly for a long time, because its elimination is 
slow. In the former, hydrotherapy, massage and tonics should be 
used as preliminary or concomitant measures. Cardiac symptoms 
are due almost wholly to the potassium salt, but especial care in the use 
of all bromides is indicated in cases of senile epilepsy (myocarditis, 
arteriosclerosis, endocarditis) or of great nutritive exhaustion, in 
which, combination with digitalis or strychnia is indicated. In bromism 
the reflexes are decreased, particularly the pharyngeal reflex, but 
Englehardt has shown that it is weak in 17 per cent, and absent in 25 
per cent, of normal individuals, whence Ziehen watehes the corneal 
reflex, which is never normally absent. In advanced bromism there is 
low temperature, bronzed skin, vasomotor relaxation, somnolence, 
apathy, paralytic speech, muscular relaxation, ataxia, tremor, fcetor ex 
ore, anorexia, slow respiration (the usual cause of death), weak heart, 
abolition of sensation in the skin and mucous membranes and of all 
reflexes, and decrease or suppression of urine. The drug therapeutically 
unites with the nerve cell and depresses its activity and metabolism, 
and toxicologically it causes its degeneration or atrophy. The drug 
must be used for months or years, and the symptoms above enumer- 
ated must be watched for; it seems that epileptics have a certain 
tolerance for bromides, which Voisin considered almost as a food in 
this affection. 

Results. — Gowers noted immediate relief in 43 per cent., improve- 
ment in a short time in 47 per cent., and no effect in 10 per cent, of 
his cases. He gives a dram a day of the potassium salt, for two 
years, for he finds that larger doses are no more efficacious; in 
nocturnal epilepsy a large dose should be given at bed-time. Seguin 's 
results were: cessation of attacks in 23 per cent., notable decrease in 
40 per cent., no great effect in 26 per cent., no effect in 10 per cent. 



INFANTILE CONVULSIONS 1209 

Charcot's method was to give a daily dose of one dram, which was 
gradually increased to nearly two, and was then slowly decreased to 
the original amount. Erlenmeyer's formula is extensively used, and 
gives the best results (sodium and potassium bromide each two parts, 
and ammon. bromide one part). The best results are obtained in 
cases which are treated early in their course and early in life, and in 
those in which there are long intervals between attacks. Opium, 
belladonna, nitroglycerine, digitalis and chloral are of but secondary 
importance, although with special symptoms they may reinforce the 
bromides. Nitroglycerine may be useful in petit mal. Children 
tolerate large doses of bromides (as well as of mercury, belladonna and 
arsenic). 

4. Treatment of the Attack. — This is confined to cases in which 
aurse are present. The patient is placed on the bed or ground to avoid 
injury, and a towel inserted between the teeth to prevent biting of the 
tongue. Compression or manipulation of the limb in which the aura 
is felt may in a few instances avert the spasm. Charcot placed an ice- 
bag over the head and one over the heart. Inhalations of amyl nitrite, 
ether or chloroform are sometimes beneficial. 

5. Surgical Indications in Traumatic Epilepsy ( Jacksonian or general- 
ized). — Biswanger's conclusions are (a) that results are disappointing; 
only a small percentage of cases actually recover; operation is indicated 
(6) when convulsions emanate from a small cortical focus; (c) when 
the convulsions are of a type intermediate between the Jacksonian and 
generalized form; (d) when, with generalized convulsions, there is a 
suggestive scar, bone defect or localized tenderness on percussion; (e) 
since the internal lesion does not always correspond with the external 
scar, the site of trephining should be governed by focal symptoms, 
motor or sensory aurse, or "exhaustion" signs; (/) cysts, tumors, bone, 
membrane or scars may be removed, but not the cortex (as recom- 
mended by Horsley) ; (g) operation must be followed by the bromide 
treatment; (h) operation is contra-indicated in ordinary epilepsy. 



INFANTILE CONVULSIONS. 

In young children the nervous tissues are incompletely developed, 
many axis cylinders are not yet clothed with myelin sheaths, and the 
lower dominate the upper segments, thus predisposing the child to 
disproportionate nervous reaction. 

Etiology. — (a) Rickets as a cause was especially emphasized by Wm. 
Jenner. Many cases of carpopedal spasm, tetany and laryngismus 
stridulus have a rhachitic basis; this form occurs in infants between 
the eighth and twenth-fourth months of life, is likely to recur, and dis- 
appears after the second year, (b) Reflex spasms may be caused by 
peripheral irritation, as from dentition and worms, though the 
importance of reflex irritation has been greatly overestimated; 
gastro-intestinal irritation or auto-intoxication, phimosis, and otitis 



1210 DISEASES OF THE NERVOUS SYSTEM 

media, are possible causes, (c) They may be due to gastro-intestinal 
intoxication, which results in debility, malnutrition or a "hydren- 
cephaloid" condition (Marshall Hall), which has been described above 
under various captions and is usually of most serious import, (d) 
Nervous affections, trauma during delivery, meningitis, tumor, sinus 
thrombosis, severe coughing, acute encephalitis (cerebral hemiplegia), 
or acute poliomyelitis, are etiological factors, (e) They may result from 
acute infections, as scarlatina, measles, or pneumonia, in which 
convulsions and vomiting rather replace the chill which is more 
common in adults. (/) Genuine epilepsy may begin in early life; 12 
per cent., according to Gowers, and 40 per cent., according to Osier, 
occurs in the first three years of life. 

Symptoms. — The symptoms resemble those of epilepsy in most of 
its phases, but they are, however, less developed in the eclampsia of 
children. It usually begins in the hands, and the seizure is partial, 
tonic, intermittent, and carpopedal rather than generalized. Screaming 
and grinding of the teeth may occur. The laryngeal spasm has already 
been described under affections of the vagus. 

Treatment. — The occurrence of the convulsion is the first indication 
for treatment, and should be met symptomatically by inhalations of 
chloroform or nitrite of amyl, followed by grs. vto x of chloral, and 5 SS 
of bromide by rectum. The bromide should be given for several days, 
for its effects are cumulative rather than immediate. Opiates should 
generally be avoided in children under five years, especially in nurslings; 
if given to them at all the dosage should be one-half the dose according 
to the rule of age, i. e., 2V of the adult dose in a child of one year, instead 
of tV of the adult dose. Opiates should not be used in weak or marantic 
infants. The hot bath is of little service. 

The cause is then determined and treated, as (a) the rickets, and (b) 
the peripheral irritation; lancing of the teeth is practiced less and 
less; (c) in gastro-intestinal intoxication the stomach should be 
emptied by ipecac or by means of the stomach tube; lavage of the 
bowel is indicated in acute cases and stimulants should be given in 
cases of some standing, (d) The bromides should be administered as 
in epilepsy. 

CHOREA AND CHOREIFORM AFFECTIONS. 

The name is given to several convulsive maladies. Chorea, or St. 
Vitus dance, known to Paracelsus, was endemic in the middle ages and 
is now often known as chorea major; it was hysteria or possibly 
epilepsy. Chorea in its usually accepted sense was described by 
Sydenham and is known as Sydenham's chorea, chorea minor, or 
infective chorea. 

Definition. — Sydenham's chorea is (a) a neurosis of late childhood; 
(b) it is characterized by subacute onset, limited duration and, usually, 
recovery; (c) it is probably cortical in localization, as indicated (d) 
by involuntary irregular spasmodic movements, and (e) increased 



CHOREA AND CHOREIFORM AFFECTIONS 1211 

incoordination on voluntary efforts; (/) it is always associated with 
some psychical weakness, irritability or alteration in character and 
(g) is frequently associated with rheumatism and (h) endocarditis. 

Etiology. — (a) Age: 80 per cent, of cases occur in persons between 
the fifth and fifteenth years; 90 per cent, in those between the fifth and 
twentieth years; it is most frequent at the sixth and seventh year of life, 
or at puberty, (b) Sex : Seventy per cent, of cases are in girls (Gowers, 
Osier), (c) Rheumatism has been considered a cause since B right's 
time and this theory has been established especially by English writers. 
The French writers probably overestimate its importance, and the 
Germans apparently underestimate it. Rheumatism is a factor in at 
least 20 to 25 per cent. (Hughes and See) ; some consider it causal in 
45 or even 70 per cent, of cases. Endocarditis, rheumatism and chorea 
are too frequently associated to escape serious attention. Rheum- 
atism occurs mostly before the chorea, but in 4 per cent, of cases 
do the two occur simultaneously. Their association is most frequent 
in the young, but their exact relation cannot be established until the 
cause of rheumatism is known. Rheumatism, endocarditis and chorea 
are probably correlated, i. e., are due to a common virus, (d) Other 
acute injections are causes in 43 per cent, of cases (Neumann). Chorea 
has been observed after gonorrhoea, puerperal fever, sepsis, pertussis, 
measles, typhoid, etc. (e) Pregnancy is a predisposing cause in women, 
particularly before the twenty-fifth year. Chorea occurs in the first 
three months, especially in first pregnancies and is most severe in 
character. It rarely occurs postpartum. Giles de la Tourette justly 
holds that many cases classified as chorea are really hysteria. (/) 
Neuropathic heredity is observed in 16 per cent, of choreic subjects, 
which probably explains its frequency in Hebrews. This factor has 
seemingly been overestimated. (g) Other causes are sometimes 
operative, as fright, trauma, and reflex irritation from nasal or digestive 
disease, as worms. It occurs in the lower classes, is sometimes due to 
iodoform or mercurial poisoning, apparently occurs when the baro- 
meter is low, and is influenced by the poor hygiene, excitement, 
exhibition and competition of the school-room; this is called the 
"school-made chorea" by Sturges. 

Pathology and Pathogenesis. — The disease is a provisional neurosis, 
since no constant pathological findings exist. The following changes 
have been recorded; hyperemia, exudation about the arteries, areas 
of softening, punctate hemorrhages, round hyaline bodies in the peri- 
vascular lymph sheaths (Flechsig, Wollenberg, Jakomenko), and 
swelling and turbidity of the large pyramidal cells of the cortex (Tur- 
ner); but none of these are characteristic or constant. In fatal cases 
endocarditis is the most frequent finding (90 per cent. Osier, 94 per 
cent. Sturges), and Osier notes that its frequency is greater even than 
in rheumatism. Kirke's theory of cerebral embolism has been rather 
generally abandoned. The bacteriological findings are negative or 
conflicting. It is probable that the irritation, whether the result of 



1212 DISEASES OF THE XERYOUS SYSTEM 

exhaustion or of toxaemia, is either cortical or in the basal ganglia, 
which are closely connected with the cortex or subcortex. 

Symptoms. — 1. Onset. — Prodromes are infrequent, but sometimes 
there is a subacute onset, with irritability, restlessness, depression, dis- 
turbed sleep, headache, anorexia, rheumatic pains or sensory irritation. 
The affection usually begins with motor disturbance, in the form of 
involuntary movements and incoordinate voluntary movements; the 
latter are often misunderstood and punished, for the child cannot sit 
still, or breaks or drops things. 

2. Chorea Movements. — These are involuntary, although they may 
seem voluntary, as the thrusting out of the tongue or the reaching of 
the arm at an object. They are ''irregular in time, character and 
degree," are often long, are not usually attended by fatigue or pain, 
are incomplete and without motive, are increased by attention being 
drawn to them and by excitement and almost always cease during sleep. 
They usually begin in the arms, and later extend to the face and legs. 
Chorea very often begins on one side, especially the right, whence it 
extends to the other side but sometimes remains unilateral (hemi- 
chorea); both sides, however, are always involved to some extent. The 
face is contorted with varying expressions, now grimaces or again 
motiveless smiles; this is the fades choreatica of Sachs. The eyes roll, 
are disturbed especially when attempts are made to fix them, and 
diplopia is not uncommon. The pupils are often wide and react 
slowly. Tuckwell describes a case in which the teeth were broken. 
The author recently saw with Dr. Halbert a similar instance in which 
many of the teeth were broken. Speech is involved in 25 per cent, of 
cases ; this is due rather to difficult articulation by the tongue and lips 
than to phonation. Speech is quicker than normal, like the movements 
of the arm, and may be aggravated by irregular movements of the 
glottis and respiratory muscles, resulting in panting, irregular inspir- 
ation or expiration or sobbing sounds in which the diaphragm partici- 
pates. Aphasia is less frequent. The arms are most involved; they are 
flexed, extended, pronated and supinated ■ in tireless succession. 
Bouillaud spoke of the movements as muscular insanity (folie mus- 
culaire). The trunk is sometimes involved in light cases, and distinctly 
so in the severe types. The movements are sometimes so violent as to 
throw the patient out of bed. The legs are usually much less involved; 
there is a zig-zag gait, and walking may be impossible. Besides hemi- 
chorea, other irregularities are at times encountered, as monochorea, 
chorea paraplegica, or chorea alternans. The muscular power and 
endurance are often said to be normal. Some writers, as Wallenberg, 
insist that paresis is no part of chorea, but Gowers and Osier speak of 
marked muscular weakness. Two forms are distinguished: (a) paresis 
with chorea, in which the muscular power is reduced, as in the usual 
case, and (b) limp or paralytic chorea (Todd, West, and the choree 
molle of French writers). The paresis may be of the mono-, para- or 
hemiplegic type. 



CHOREA AXD CHOREIFORM AFFECTIONS 1213 

3. Psychical Changes. — These are constant, and resemble an acute 
cerebral neurasthenia in the undue irritability and ready fatigue 
which are manifested. The subject is wilful, forgetful, emotional, 
irritable, unable to concentrate the attention or to remember perfectly. 
Marked alteration in addition to these changes may occur, as com- 
plications, viz. j delirium, mania, melancholia or hallucinations; 
chorea insaniens has a most unfavorable prognosis. Combination with 
hysteria is frequent, with epilepsy infrequent. Hughlings Jackson 
found paroxysmal headache in 90 per cent, of cases. 

4. Sensation. — Sensation is usually normal. Tenderness over the 
spine and peripheral nerves is not common, though S. Wier Mitchell 
and Triboulet described a painful chorea. Occasionally there is a 
tingling sensation and numbness. Blocq and others have insisted 
that sensory alteration is referable to hysteria, but Triboulet finds that 
there is usually some reduction of sensation. 

5. The Reflexes. — These are difficult to study, and are often said to 
be normal. They are normal in 50 per cent., and decreased or absent 
in 50 per cent., although Joffroy usually found the patellars decreased 
or absent, and Oddo found the tendon reflexes (a) rarely increased, 
(b) normal in light cases only, and (c) as a rule decreased or absent 
(absent on one side in 80 per cent., on both sides in 50 per cent.). 
The bladder and rectum are usually normal save in the severest forms. 

6. Electrical Reactions. — The electrical reaction and mechanical irri- 
tability of the muscles are with few exceptions unaltered. 

7. The Heart. — Irregularity is common, and is often due to irregu- 
larity in breathing (pseudo-arrhythmia). A slight increase in rate is 
due to the general neurosis. It has been claimed that chorea may 
affect the "muscles of organic life"; Ollivier, Roger and Simon have 
written of cardiac chorea, which probably does not exist. Functional 
murmurs are frequent, especially in thin nervous children, from the 
altered condition of the blood, the toxsemia, and increased cardiac rate. 
They may be confused with incipient endocarditis. Great conser- 
vatism must be exercised in their prognosis and diagnosis (see Diag- 
nosis of Mitral Insufficiency). 

Endocarditis has been mentioned in the definition of the disease 
and its causation and pathology (90 to 94 per cent, of fatal cases). It 
was found in 66 per cent, of Osier's cases without rheumatism. It is 
rarely malignant, but may produce embolism. Mitral lesions, especi- 
ally insufficiency, are the most common form. The importance of 
latent endocarditis, i.e., without clinical symptoms, has been empha- 
sized by Osier, Oxley and Grosse. Pericarditis is not frequent, though 
it is found in 20 or even 26 per cent, of cases, in certain statistics. 
Heart disease is found in 50 per cent, of cases in which there have been 
two attacks of chorea, and in 100 per cent, of those having over three. 

8. The Skin. — Herpetic eruptions and pigmentation result from 
medication by arsenic. Urticaria, erythema nodosum and purpura 
are sometimes observed, as well as the rheumatic nodes first described 
by Maynet and later by Barlow and Warner. 



1214 DISEASES OF THE NERVOUS SYSTEM 

9. General Symptoms. — Emaciation occurs chiefly in the severer 
types. The urea and phosphates are often increased. Albuminuria 
is rare, except as a result of renal embolism. The temperature is not 
often elevated, save from cardiac and other complications; even in 
chorea insaniens it rarely passes 102°. 

Course and Prognosis. — The average course of mild cases is from 
six to ten weeks, and six weeks to six months is the average duration of 
all varieties. In very rare instances the disease may last six (Gowers) 
or even sixty years (Meldner). Three main types are distinguished: 
(a) The mild type, in which the patient is nervous, irritable, has but 
slight choreic movements and is often dyspeptic and sometimes 
anaemic; (b) the severe form in which the spasmodic movements are 
severe and general; (c) the maniacal type (chorea insaniens), which is 
most often observed in adult or pregnant women, and sometimes at 
puberty. The movements are incessant and extreme, and are ofteu 
associated with fever, constant insomnia and great psychical disturbance. 
As a rule, the shorter the duration the more intense are the symptoms. 
The tendency td recurrence was noted by Sydenham. Relapses occur 
in 25 to 33 per cent, of cases. One year is the average interval, and 
when there is no recurrence within one and one-half years, it is probable 
that none will be observed (Gowers). Germain See held that relapses 
were most likely to occur at the sixty-ninth day. Recovery is the rule; 
the mortality averages between 2 and 3 per cent. Twenty to 25 per 
cent, of pregnant cases die. Fatality is greatest at the age of puberty and 
in adults. As Charcot remarked, death occurs less often from compli- 
cations, as endocarditis, than from toxaemia, fever, mental changes, 
emaciation, delirium, and coma. In all cases rise of temperature or 
obstinate insomnia is ominous. Though the immediate outlook is 
not influenced by endocarditis, it is a most important feature in the 
ultimate prognosis of a complete recovery. Intercurrent fevers may 
dissipate the spasms. While complete recovery is generally expected, 
in rare instances distinct psychical changes (Jolly) or permanent chorea 
may remain (v.s.). 

Diagnosis. — Recognition of the disease is usually most easy, after 
one has seen a typical case, and when one bears in mind the conception 
(definition, q.v.) of the disease. 

Differentiation. — Simple tremor or the intention tremor of mul- 
tiple sclerosis is easily separable. The hemichorea of hemiplegia 
(see Diagnosis of Cerebkal Hemorrhage) or the bilateral chorea 
of infantile cerebral paralysis (q.v.) is easily distinguished by the history 
and course. Friedreich's ataxia is differentiated by its slow, irregular, 
incoordinate movements, nystagmus, its frequent family incidence, 
the scoliosis, talipes and slow, scanning speech. Hysterical chorea (so- 
called) is rhythmic, more regular and frequently produces sudden 
(" electrical") movements, as bowing or salaaming, nodding the head, 
etc. Chorea major is easily distinguished. Chorea in the original 
sense is chiefly of historical interest; it was a pandemic or epidemic 
hysteria provoked by religious excitement. Its victims made pilgrim- 



CHOREA AXD CHOREIFORM AFFECTIONS 1215 

ages to the shrine of St. Vitus whence the name of the disease. Simi- 
lar outbreaks occurred in Kentucky among the early settlers. This 
form closely resembles the saltatoric spasm described by Bamberger 
in 1859, in which the legs contract on attempting to stand, causing 
jumping or springing movements. It may be transitory, or may last 
for years, and occurs chiefly in neurotics. Beard and Thornton, quoted 
by Osier, have described a similar neurosis which was endemic in 
Canada among the " jumping Frenchmen." The "holy rollers/' and 
jumpers of Russia and Java probably come under this head, or under 
impulsive tic (v.i.). 

Huntingdon's chorea has no connection with Sydenham's type. 
Chronic chorea comprises two forms: (a) The senile form, in which 
the mind is less involved, the course more benign than in (b) the 
hereditary form of Huntingdon. Although it was described by Walters 
(1842) and Lyons (1863), Huntingdon in 1872 brought out the cardinal 
features of the disease as observed on Long Island. These are (i) the 
late and gradual onset after the thirtieth year, more marked in males 
than in females; (ii) its hereditary character, sometimes involving 25 
or 50 per cent, of the family, sometimes skipping generations, or lasting 
for generations or even for two centuries in a family (Osborn) ; (iii) its 
progressive character, and (iv) the resulting mental degeneration, end- 
ing in slow dementia, often with epileptiform attacks or suicidal 
tendencies. The precise pathology of Huntingdon's type is not known. 
Pachymeningitis, haematoma of the dura, or less often chronic encephalo- 
meningitis, vascular disease and atrophy of the convolutions have been 
present in the isolated autopsies made. The etiology is unknown. 
Clinically it is characterized by irregular movements, which usually 
begin in the hands, are somewhat controlled by voluntary effort, and 
are more irregular, incoordinate and slow than in acute chorea. Slow 
spasmodic facial contortions are observed, and the speech becomes 
first slow and hesitating, and later quite indistinct. The gait is un- 
steady and swaying. Writing is interfered with, the reflexes are 
moderately increased, sensation is normal save that the muscular sense 
is somewhat blunted, and dementia develops. The disease is incurable, 
although somewhat benefited by opium and bromides. 

Tic must be differentiated. The term is now used to designate an 
"habitual, conscious, convulsive movement resulting in the involuntary 
contraction of one or more muscles, abruptly reproducing some reflex 
or automatic action of every-day life" (G. Guinon). There are two 
forms. 

(a) In simple tic, (i) localized spasm, habit spasm, or habit chorea, 
which is said by S. Wier Mitchell to occur in girls between seven and 
fourteen years of age, may result from lesions of the nose or throat or 
possibly from eye-strain, and includes movements such as winking, 
drawing of the mouth, sniffing, shaking the head, and shrugging the 
shoulders. It usually ceases, but may last into adult life, and the 
"child's attention should not be drawn to the movements," although 
the writer believes that judicious reminders and discipline inhibit 



1216 DISEASES OF THE NERVOUS SYSTEM 

these habits. Arsenic may be beneficial, (ii) The electric chorea 
(Henoch and Bergeron) consists of short, lightning-like contractions 
in special muscles, as those of the neck or shoulders, as though the 
muscles were electrically stimulated, (iii) Dubinins disease (1846) 
consists of contractions of the arms and legs, followed by hyperesthesia, 
pain in the head and back, muscular atrophy, paresis and sometimes 
fever and convulsions. It is endemic in Lombardy, its cause is 
unknown, and it is usually fatal from apoplexy or coma, (iv) Para- 
myoclonus multiplex, or myoclonia, which was described by Friedreich 
in 1881, is an affection of sudden onset, with symmetrical, involuntary, 
arrhythmic, quick, clonic contractions of the upper parts of the arms, 
legs and trunk, sometimes of the face and tongue, and occurs without 
loss of consciousness. The contractions number from 10 to 150 a 
minute, and may terminate in a tetanic contraction. It affects male 
adults chiefly (75 per cent.) and follows mental or emotional agitation, 
so that some would classify it under hysteria. The myotatic irritability 
and reflexes are increased, the mind is usually normal, although some- 
times fixed ideas are observed, hiccough is occasional from involvement 
of the glottis or diaphragm, voluntary movement is decreased or some- 
times arrested, there are no sensory symptoms and the outlook is 
usually good, although the course may be long and relapsing. Treat- 
ment consists of administration of voltaic electricity, nervines and bro- 
mides. The family form, described by Unverricht, with epilepsy and 
spasms of the tongue, and deglutition, is probably a subtype of heredi- 
tary chorea. 

C. Oddo gives the following general differentiation between 
Tic and Chorea. 

Form of movement: pseudo-intentional, Incoordination and great variability, 
with repetition. 

Rhythm: rhythmic, brusque, short, Arrhythmic, slow, not synchronistic, 
synchronistic. 

Will: suspends movements. No action. 

Accessory signs: muscular power pre- Myasthenia; modified reflexes and 
served; normal tendon reflexes and sensation, 

sensation. 

Etiology: hereditary degeneration. Neuropathic tendency. 



(by Tic with explosive utterances, impulsive tic or Gilles de la Tour- 
ette's disease, is closely affiliated with hysteria and monomania. It 
occurs in neurotic individuals between the sixth year and puberty. The 
cardinal features of the psychosis are : (i) Involuntary movements in the 
face and arms, or in all the muscles in severe types, when the movements 
become violent or explosive, (ii) Explosive utterances, resembling 
a bark, occur; the patient repeats words he hears (echolalia) or mimics 



CHOREA AXD CHOREIFORM AFFECTIONS 1217 

movements (echopraxia); the child may use obscene or profane words 
(corprolalia), which was considered by de la Tourette to be most 
characteristic, (hi) The subject has fixed ideas. These include: 
arithmomania, in which every action is preceded by counting or doing 
a certain thing a given number of times; a fear of contamination 
{delere du toucher); onomatomania, or repetition of a given word or 
name; folie pourquoi, demanding the reason for everything. The 
prognosis is usually unfavorable. 

(c) In complex coordinate tic, as thumb sucking, rocking in the bed, 
and bumping the head, the outlook is favorable (Gee and Hadden) 
when it does not occur in feeble-minded children. 

Treatment of Acute Chorea.— l. Prophylaxis. — This may produce 
results; sensible methods of education should be adopted, the hours in 
the overheated, foul school-room should be short, and the useless 
forcing of children by marks, prizes and exhibition should be aban- 
doned. Children can be taught more in an hour or two of judicious 
individual instruction than in the five or six confining hours which 
their wandering attention must endure. Prevention may concern other 
etiological factors (q. v.); for instance, the nose should be examined 
for sources of irritation, as adenoids. 

2. Rest in Bed. — The results obtained by rest in bed and isolation 
are as rapid as those of any medicinal therapy. It not only saves tissue 
waste, but is the best prophylactic and symptomatic treatment of 
possible or actually established endocarditis. 

3. Skin. — The skin is very often dry and harsh, whence it must be 
given special attention. Diaphoretics frequently produce beneficial 
effects. The stimulation of the skin by proper covering and by hydro- 
therapy is the simplest and least injurious method. The refrigerant 
diaphoretics, and full warm baths, give the best results. The skin must 
be kept clean, and in severe cases, the water-bed must be used. 

4. Trauma. — Trauma is prevented in severe types by padding the 
beds by mattresses and pillows, since the violent movements may even 
throw the patient to the floor. Sepsis is a frequent occurrence, and is 
most dangerous. The temperature must be taken by rectum. 

5. Exhibition of Drugs. — (a) Fowler's solution is the most frequently 
used and the oldest remedy, and apparently gives the best results. 
It should be given in increasing doses (see Treatment of 
Pernicious Anaemia, for detailed action); children tolerate large 
doses of arsenic exceptionally well. It may be administered hypoder- 
matically or by clyster when the digestive tract is irritable. Arsenic is 
not without its dangers. C. Gamble, Jr., records an instance of fatal 
arsenical poisoning in a case to whom about 1-j ounces of Fowler's 
solution was given in a month (including an intermission of one week). 
It appears that rest in bed, and administration of a placebo, as mix 
vomica, has given equally good results, but any individual series of 
cases may be misleading, (b) Salicylates are of benefit only when 
rheumatism actually co-exists, and acetanilide is indicated only in the 

77 



1218 DISEASES OF THE NERVOUS SYSTEM 

initial stages. In other words, the antirheumatic remedies are less 
important in the treatment than is rheumatism in the etiology, (c) 
Depressomotors: The bromides rarely cure the movements, although 
they often quiet the mild psychical manifestations. Chloral has been 
recommended and given in large and continued doses, to produce sleep 
or continuous sleep. This method merely demonstrates the tolerance 
of the body for dangerous remedies, and as stated before, chloral can- 
not be given safely, in amounts exceeding a dram for adults in three 
divided doses at intervals of an hour. Morphine is generally considered 
dangerous and inferior to chloral. Small doses often accentuate the 
mental agitation, but if combined with chloral, hyoscine and bromide, 
it may give at least temporary relief, (d) Strychnine is valuable 
(Trousseau), especially in the later stage, when recovery is slow, (e) 
In chorea gravidarum, abortion or premature delivery is indicated. 



TETANY. 

Definition. — Tetany, which was first described by Steinheim (1830) 
and Dance (1831) and named by Corvisart, consists chiefly of (a) 
peculiar tonic, intermittent, bilateral, painful spasms, mostly in the 
extremities, without involvement of the sensorium and (b) increased 
mechanical and electrical excitability of the nerves. 

Etiology. — (a) It occurs endemically or epidemically, especially in 
Vienna, Heidelberg, Berlin and Syria, and it is prevalent during March 
and April. It is rare in America, England and Italy. Though once 
frequent (1830-1860), it is now uncommon in Paris. In the Vienna 
outbreaks 46 per cent, of cases occurred in shoemakers, and 24 per cent, 
in tailors who were otherwise healthy. Tetany occurs among the 
poorer classes. Eighty-three per cent, occurs in persons between six- 
teen and twenty-five years of age. It may develop in an entire family. 
(b) Digestive affections may produce it, as dilatation of the stomach 
(Kussmaul, 1871), dyspepsia, ulcer or cancer of the stomach or duo- 
denum, often with pyloric obstruction; auto-intoxication is the most 
probable cause of this group. Only 80 cases of gastric tetany are on 
record, (c) Rickets is causal in 85 to 90 per cent. (Seeligmuller) and 
in 96 per cent. (Cassel) of the infantile types. Some writers — incor- 
rectly, we think — consider that the infantile carpopedal spasm is 
tetany, (d) Tetania strumipriva is a type of tetany which follows 
removal of the thyroid in 15 per cent, of cases (Albert, Mikulicz, 
Kocher). It disappears wmen a new thyroid is implanted, and re- 
appears on its removal. Animals deprived of the thyroid present 
symptoms practically identical with those of tetany. If one-fifth of the 
gland is left, it usually prevents tetany (von Eiselberg), but this fraction 
must be healthy. It may be true that the thyroid is less important than 
the parathyroid glands. (See pages, 895 and 896). (e) Tetany occurs 
also in the acute infections, sepsis, nephritis, puerperal or nursing women 
and rarely in intoxications with ergot, morphine or lead. There are 



TETANY 1219 

recorded only 32 cases of the puerperal form. The only two cases which 
the author has seen in this country occurred with florid secondary 
syphilis. It may develop with other nervous disease, and French writers 
have attempted to class it under hysteria. No pathological changes have 
been observed in the brain or nerves; in a few cases there has been 
cloudiness with swelling of the anterior horns. Fifteen cases are reported 
in America (Howard, 1906). 

Symptoms. — 1. The earliest and chief symptom is the muscular 
contracture, which usually commences in the hand, with stiffness, 
numbness, and pain, and culminates as a tonic, symmetrical, painful 
contracture. The muscles of the hand are hard; the attitude is that of 
the accoucheur's hand, that of the hand in writing, or that observed 
in paralysis agitans ; it is produced by contraction of the ulnar flexors ; 
less often it resembles the clenched hand of old hemiplegic contracture, 
and the nails even, enter the palm; rarely the fingers are tonically 
spread apart. Except in light forms, the spasm cannot be overcome 
by force. The wrist may be flexed. The foot is affected less often than 
the hand, and the spasm draws the foot into the equino-varus position, 
with the toes flexed and the sole hollow. The spasm is usually limited 
to these parts, causes pain, lasts from minutes to hours or even days, 
disappears, and usually recurs later. In rarer and more severe cases, 
the parts above the elbows and knees may participate, with adduction 
of the arms and thighs, cramping of the face, neck, chest, tongue, 
diaphragm, and ocular muscles, with diplopia, spasticity of the sphinc- 
ters with retention, dysuria, etc. 

Laryngismus stridulus (Clark, 1815) is common in infantile rickets, 
in which clonic contractures also occur. The muscles are somewhat 
weak and tremor is frequent. 

2. Trousseau's sign consists in producing the spasm by pressure 
over the nerves, for example, just above the elbow or over the peroneal 
nerve, for a few seconds or from one to five minutes. It is wholly due 
to nerve pressure, not to pressure on the vessels, and is pathognomonic. 

3. There is increased electrical irritability (a) of the motor nerves 
to the galvanic current (Erb's sign) with early anodal closing and 
cathodal opening tetanus. Anodal opening tetanus is found in this 
disease alone. There is also increased electrical irritability (b) of the 
sensory nerves (Hoffmann) and (c) of the nerves of special sense 
(Chvostek, Jr.), to faradic and galvanic currents. 

4. Increased mechanical irritability of the motor nerves {Chvostek' s 
sign) is observed on tapping or pressing on the facial, median, ulnar or 
other nerves, which produces contraction of the muscles supplied by 
them. It is quite constant but may be absent in children and is not 
pathognomonic, having been found in normal persons, in cases of 
bulbar paralysis, in the major neuroses, and in convalescing cases of 
facial paralysis. (Some of these may have been atypical tetany). 
The muscles themselves are not overexcitable. 

5. Other symptoms may be present. The sensorium is usually 
clear, except in rare cases with pyloric stenosis. The special senses are 



1220 DISEASES OF THE NERVOUS SYSTEM . 

normal; optic neuritis is extremely rare. Headache and malaise are 
frequent. In contrast to the pain and paresthesia, objective sensory 
findings are absent. In rare cases epileptiform seizures are seen, which 
are probably due to thyroid changes. The reflexes are usually normal. 
The temperature is elevated in 10 to 15 per cent, of cases, but may be 
normal or subnormal. In very rare chronic cases, trophic, vasomotor 
and secretory disturbances may occur, as oedema, polyuria, glycosuria 
or falling out of the hair. 

Diagnosis. — The diagnosis in typical cases is most easy from the 
cardinal signs: (a) the peculiar spasms; (b) Trousseau's, (c) Erb's 
and id) Chvostek's signs. In epilepsy these signs are absent, and the 
aura, the cry, falling, tonic and clonic convulsions, biting of tongue and 
involuntary urination are characteristic; in very rare instances the two 
affections co-exist. Hysteria mimics everything, but the cardinal 
symptoms, except the spasms, cannot be reproduced; it has its own 
stigmata; certain reported epidemics of tetany, as at Gentilly, were 
clearly hysterical. In adults atypical forms without spasm are recog- 
nized by the other cardinal signs (b, c, d) which easily separate tetany 
from the occupation neuroses and acroparesthesia (v. i.) In children 
meningitis and brain tumor are distinguished on careful examination. 
The rhachitic relations are important even though the extreme state- 
ment that all tetany in children is rhachitis, cannot be admitted. 

Prognosis. — The outlook is good in most cases, and the course 
covers from two to four weeks as a rule. Recurrences are not infrequent. 
The etiological prognosis naturally varies, but generally speaking, 
death occurs not from tetany but from dilated stomach, or ablation of 
the thyroid. Cases may die from laryngospasm. In a recent review of 
his cases, Frankl-Hochwart concluded that the prognosis is worse than 
is usually stated; 20 per cent, of his cases died, 20 remained well, and 
the balance had recurrences and serious disabilities. 

Treatment. — The treatment varies with the cause, (a) Rest and 
quiet are indicated on general principles, although cases of tetany are 
influenced very little by excitement. Massage, strychnia and electricity 
should of course be avoided. Change of occupation and location, at 
least temporarily, are advisable in the endemic form, (b) In the 
digestive form, washing out the stomach and bowels in suspected cases 
of auto-intoxication may induce severe spasms. These cases are both 
dangerous and obstinate. The spontaneous mortality in gastric tetany 
is 70 to 80 per cent. ; with operation for pyloric stenosis, these figures 
are reduced to 37.5 per cent, mortality, (c) In the rhachitic form, 
dietary regulation and improved hygiene are necessary, and phos- 
phorus and iron are indicated. Inhalations of chloroform in some 
cases irritate the sensitive larynx, (d) In tetania strumipriva, thyroid 
feeding is usually of no value, as the mortality (80 per cent.) shows; 
successful thyroid implantation gives relief, (e) Cases following acute 
infections usually have a spontaneously short course; those occuring 
in pregnancy rarely indicate abortion; in nursing women, weaning 
gives prompt relief; for intoxications there are obvious indications. 



OCCUPATION OR FATIGUE NEUROSES 1221 

In general, drugs are of little value; chloral is indicated a priori, be- 
cause of its influence on the motor nerves, but it is inferior to the 
bromides, as is also morphine, except for pain. Sweating and digitalis 
in nocturnal forms of tetany have apparently helped some cases, but 
the disease usuallv runs its limited uninfluenced course. 



OCCUPATION OR FATIGUE NEUROSES; WRITER'S CRAMP. 

The continuous, hard, improper use of coordinate, functionally asso- 
ciated muscles may result in their cramping. Writer's cramp (grapho- 
spasms, mogigraphia) was first described by Charles Bell (1830), and 
especially studied by Duchenne and Benedict. Neuropathic tendencies 
are noted in most cases; 83 per cent, occurs in males, 93 per cent, occurs 
in those between twenty and sixty years of age, and most of these cases 
develop between twenty-five and thirty-five. Worry is a frequent factor ; 
cold, trauma, neuritis and neuralgia are possibly factors. The disease 
practically never occurs in those who write properly, i. e., move the 
arm from the elbow or the shoulder, but develops in those who use the 
little finger or wrist as the basis of movement. The affection is located 
in various centres; some hold that it is in the coordinating cortical or 
subcortical centres; it is clearly not in the muscles or nerves, for their 
other movements are often normal; the occasional atrophy and paresis 
may suggest localization in the cord. 

Symptoms. — The symptoms come on gradually, with fatigue, pain 
and cramping in the muscles of the fore-fingers and thumb, which may 
extend to the forearm or shoulder. There may be the "lock spasm" 
of Mitchell, in which the pen is spastically held or it may be thrown from 
the fingers. On rest, the tonic spasm disappears but reappears with 
attempts to write. In Benedict's classification we find the spasmodic, 
paralytic, tremulous and neuralgic forms, which are of less interest as 
types than as showing the various symptoms, which are often combined 
in a single case. Vasomotor symptoms may occur, as flushing, or 
glossy skin, and sometimes the faradic irritability is decreased and the 
galvanic increased. 

Differentiation, according to the type, from hemiplegic weakness, 
paralysis agitans, musculospiral paralysis, and neuralgia, is usually 
easy. Similar cramps are observed in telegraphists, milkmaids, 
weavers, cigarette rollers, tailors, shoemakers, watchmakers, and 
violin and piano players. Public speakers may suffer from similar 
neuroses of the throat, and Archibald Church also mentions spasms 
of the jaw in gum chewers and of the lumbar muscles in physicians 
who drive much. 

The outlook is poor, because the unfortunate sufferer is often com- 
pelled to write until the affection is firmly fixed, and when able, usually 
returns to the same work. In some cases the muscles may waste. 

Treatment.— Rest is essential to recovery, because treatment for 
the usual nervous symptoms alone never succeeds. Plaster casts are 



1222 DISEASES OF THE NERVOUS SYSTEM 

sometimes successfully employed. Even when the subject learns to 
write with the other hand, it often develops there. Prevention is 
possible by writing free-hand from the shoulder; holding the pen 
between the first and second fingers, use of pens with large handles, 
of quills and of forearm splints with the pen attached to the extremity, 
are also helpful. Vigour oux and Wolff use with success systematic 
gymnastics, including passive manipulations and active exercises. 



MYOTONIA. THOMSEN'S DISEASE. 

Myotonia is usually called myotonia congenita from its leading 
causal element, heredity. It was first described by Leyden, but more 
fully by Thomsen (1876), who was a victim among 20 cases in his 
own family, in five generations. This rare affection, of which there 
are about 100 reported cases, occurs chiefly in males and in Germany 
and Scandanavia. Its pathology is obscure, for the only necropsy 
which has been performed (Dejerine and Sottas) showed no nervous 
alteration. Muscle fibers, excised during life, show hypertrophy, 
decreased striation, nuclear multiplication and slight interstitial increase, 
leading Leyden and others after him to consider the process myopathic. 
Some offer the objection that these changes are artefacts. 

Symptoms. — A peculiar transient tonic muscular rigidity develops 
when the muscles are first used, which limits or arrests movement, 
but wears off as their use is persisted in. It recurs, or indeed is most 
intense after rest or when a new kind of movement is undertaken. It 
appears early in life, perhaps "in the cradle," but generally between 
the ages of four and ten, it increases as the muscles develop and then 
becomes stationary for life. In one case improvement was observed. 
The legs are more affected than the arms, but any muscle may, in 
exceptional cases, be affected, as those of the face, tongue, or bladder or 
the respiratory muscles. They are usually stronger and sometimes 
larger than normal, although some writers speak of muscular weak- 
ness. The longer the muscles are rested, the more severe is the initial 
spasm on exertion. Rigidity does not follow passive muscle movement, 
although firm pressure or a sharp blow initiates it. 

Though the tendon reflexes and the mechanical and electrical 
excitability of the nerves are practically normal, application of the 
galvanic current to the muscles produces sluggish, prolonged closing 
contractures, which are easily and equally obtained with either pole, 
and become tetanic with strong currents; this is the myotonic reaction 
of Erb. Undulatory contractures follow strong faradic stimulation. 
Subjects of myotonia are frequently irritable or hypochondriacal. 

Treatment is of little value. Thomsen believed that exercise retarded 
the disease. Cold, dampness, excitement and fatigue, are to be avoided. 

The following are allied, if not identical, affections : the congenital 
paramyotonia of Eulenberg, consisting of tonic spasms, which last 
from fifteen minutes to several hours, occur especially in the arms, 



PARALYSIS AGITANS 1223 

and often affect the eyes and mouth; it is excited by exposure to cold 
(vasomotor spasm in the muscles); and the ataxic paramyotonia of 
Gowers, in which tonic spasms may last the entire day, with muscular 
weakness, ataxia especially in the hands, and disturbed sensation or 
anaesthesia in the fingers. 



PARALYSIS AGITANS. 

This affection is also known as shaking palsy or Parkinson's dis- 
ease; it was first described by Parkinson in 1817. 

Etiology. — (a) Most cases occur in persons between the ages of 
forty and sixty- five, (b) Sixty-six per cent, of cases are men. (c) A 
neuropathic tendency is present in 15 per cent, (d) It is doubtful if 
trauma, acute infections or thyroid disease are causes. 

Pathology. — It is classed among the neuroses, because of the absence 
of any constant pathological finding. It is not strange that arterio- 
sclerosis and perivascular thickening are often found, since paralysis 
agitans occurs in "the early degenerative period." Gordinier's 
collection of cases examined by recent histological methods, shows 
that (a) general arteriosclerosis is less marked than that of the nervous 
tissue; (b) the arteries in the cord are markedly changed, and around 
them are (c) increased neurogliar sclerosis and (d) pigmentation and 
atrophy of the nerve cells and fibers. 

Symptoms. — The cardinal symptoms are (a) tremor; and (6) 
stiffness, slowness of movement, shortening and weakening of the 
muscles, (a) Tremor in 66 percent, of cases is the first symptom; it 
may develop after the muscular rigidity, and is sometimes absent 
(paralysis agitans sine agitatione). It usually appears first, and is 
most marked in the hands. It affects first one hand, and usually next 
reaches the leg of the same side, then the opposite hand, the opposite 
leg, and lastly the trunk, so that at different periods of development it 
is successively a monoplegic, hemiplegic, or finally a diplegic tremor. 
It is slow (4 to 7 oscillations per second), rhythmic, fine at the onset, 
but somewhat coarser later and in the large muscles is more marked 
in peripheral than distal parts, persists during rest, ceases during 
sleep, and ceases momentarily on voluntary action. In rare cases, it 
appears only on movement, as intentional tremor; Gerhardt found it 
increased by movement in 50 per cent. It is difficult to define precisely 
the muscles involved. In the hands it may affect chiefly the flexors 
and extensors at the metacarpal joints or the interossei, which give the 
spinning or pill-rolling movement. The wrists may be abducted and 
adducted, rarely supinated and pronated, and the arms and shoulders 
are implicated but little. The writing is tremulous. The feet are 
mostly involved at the ankles, and in the toes but little. The thigh 
adductors often tremble. Trembling is infrequent in the face, neck 
and back, while the abdomen entirely escapes. The head and body 



1224 



DISEASES OF THE NERVOUS SYSTEM 



may of themselves tremble, but much of it is imparted to them from 
the limbs. In the rarest eases, the tongue, palate, larynx and epiglottis 
tremble. 

(b) Muscular rigidity and shortening, weakness, and slowness of 
movement usually follow the tremor; slight symptoms are detected 
early, and anticipate the tremor or exist without it. These changes 
result in the following: (i) The Parkinson fades, which is mask-like 
and devoid of lines or expression; the eyelids seldom wink. The 

forehead shows transverse folds be- 
cause of the bowed head and body. 
The eyes move tardily in reading, 
and the entire body must be turned 
to enable the patient to look later- 
ally. There is also slow, monoto- 
nous, monosyllabic speech, with 
hesitation at first, but hurried at 
the finish, (ii) The attitude is char- 
acteristic, because of the flexor posi- 
tions assumed, the head and the 
chin are held forward, the neck is 
extended and rigid, the body is in- 
clined forward, the elbows are fixed 
and brought somewhat forward and 
away from the body; the fore- 
arms are brought toward the body, 
the trembling thumb and index 
finger are apposed, or the fingers 
deviate toward the ulnar side as in 
arthritis deformans, and in stand- 
ing the knees are somewhat bent and 
at times closely apposed. The body 
expression, we may say, is like that 
of the face, (hi) The gait is 
equally characteristic. Like the 
speech, it is initially hesitant, and 
later hurried. The patient, when 
once started, may not be able to 
stop himself. Trousseau spoke of 
the patients as "chasing their cen- 
tre of gravity. " This festination or 
propulsion is probably purely mechanical from the forward bodily 
inclination, although it was interpreted by Charcot as a kind of forced 
movement. To counteract the throwing forward of the centre of 
gravity, the arms may be carried behind the back. In some cases, if 
the patient is pushed backward or sideways, he may not be able to 
stop for some steps; this is retro- and later o-puls ion. (iv) The palsy 
is often slight and rarely extreme, although it may be simulated by 
the helplessness caused by rigidity. The patient is not inclined^to 




Side view of a case of paralysis agitans, show^ 
ing forward inclination of the trunk. Ten 
dency to propulsion. (Dercum.) 



PERIODIC FAMILY PARALYSIS 1225 

exertion, "moves like a piece of machinery/' as Parkinson describes 
it, and may not be able to turn over in bed. Patients have drowned 
from falling on the face in a small puddle of water. Muscular reaction 
requires 40 per cent, more time than normal. 

Other symptoms are subordinate. The mind is clear, but we may 
say stiff like the face and limbs, and a certain restlessness, irritability 
or apathy may be detected; insomnia is common and headache 
occasional. Sensation is essentially normal, although pains, pruritus, 
paresthesia and hypsesthesia are seen in 35 per cent, of cases. Vaso- 
motor disturbance most often assumes the form of a feeling of heat; 
indeed the peripheral temperature may be increased several degrees. 
Severe sweats are quite common. The pupillary, cutaneous, tendon 
and organic reflexes are normal. 

Course and Prognosis. — The onset is sometimes sudden, but usually 
gradual, and the course covers several decades. The outlook is more 
favorable in atypical than in typical cases. Remissions may occur, 
but the disease progresses steadily. Death very rarely occurs from 
the affection itself, but usually from intercurrent pneumonia or ad- 
vancing arteriosclerosis, cerebral softening, myocardial insufficiency, 
nephritis and kindred lesions. 

Diagnosis. — When there is clear development of the cardinal symp- 
toms, the disease is unmistakable. Confusion is possible in the early 
hemiplegic forms, but the absence of a paralytic stroke, and the later 
course are distinctive. Charcot and Ordenstein (1868) clearly differen- 
tiated the affection from multiple sclerosis (q. v.). The fine, senile 
tremor, the hereditary tremor of Dana, tremors due to overexertion or 
excitement, to toxic causes (alcohol, nicotine, lead, mercury, coffee, 
opium, or chloral), weakness of convalescence from acute infections, 
paretic dementia, or the neuroses (epilepsy, Graves' disease, hysteria, 
neurasthenia) are easily excluded by the absence of the Parkinson 
rigidity, facies and festination. 

Treatment. — Treatment of the probably fundamental arterioscler- 
osis may possibly retard the disease, but prophylaxis is possible in the 
early stages only. All mental and physical fatigue should be avoided. 
The administration of full doses of iodide, chloral, opiates, bromides, 
hyoscine, ergotin, conium or duboisin may mitigate the tremor, but 
always lower vitality and disturb function. 



PERIODIC FAMILY PARALYSIS. 

This affection was first described by Cavare (1853), and more fully 
by Westphal (1885); Audibert and Oddo collected 64 cases (1902), 
which Holzapple brought to 70 (1905). It is a family affection; Goldflam 
collected 11 cases in one family, and E. W. Taylor 12 in another. 
Most cases occur in adolescence, and nearly all of them in persons 
under twenty-five; it recurs every few weeks or months, possibly every 
day, or only at intervals of years. Its symptoms are almost wholly 



1226 DISEASES OF THE XERYOUS SYSTEM 

motor, producing a flaccid paralysis in the legs and arms, less often in 
the trunk, and exceptionally in the face, neck, tongue and throat. It 
occurs without apparent cause, usually during sleep, from which the 
patient awakes with a sense of fatigue, weakness, or dulness which 
develops into paralysis within twenty-four hours. Mental and sensory 
symptoms and those of the cranial nerves and special senses are rare. 
There is no fever, the pulse is often slow and cardiac dilatation has been 
observed. The deep reflexes are decreased or abolished, often also 
those of the skin, and the faradic excitability of the nerves and muscles 
is lessened or absent. The patient is well in a few hours or days, until 
another attack occurs. The disease usually subsides spontaneously 
after the fiftieth year of life. Its nature is not determined. Goldflam's 
theory of auto-intoxication is supported (a) by J. K. Mitchell, Flexner 
and Ebersoll, who found increased secretion of kreatin before and 
during the attack; (b) by Crafts and Irwin, who isolated toxins from 
the faeces; (c) possibly by the fact that potas. citrate sometimes lessens 
or aborts the seizure. Dana thought that the disease was hysterical, but 
Bernhardt and others consider it affiliated with myotonia and progressive 
muscular atrophy. Holtzapple administers potas. bromide in doses of 
thirty grains. 

MIGRAINE. 

Migraine (hemicrania, megrim, sick headache) is an hereditary 
degeneration or psychoneurosis, with the paroxysmal occurrence (in 
a complete attack) of aura?, headache, nausea and vomiting. 

Etiology. — (a) Heredity is a conspicuous cause (90 per cent. Mobius), 
either directly as migraine, or indirectly from neurotic, insane or 
epileptic antecedents. Joint affections, as gout, are often noted in 
the family history, (b) Thirty-three per cent, of cases begin between 
the fifth and tenth, 40 per cent, between the tenth and twentieth years, 
and the remainder usually before the thirtieth year. Females are 
affected a little more frequently than males, (c) Exciting causes are 
acute infections, constipation, dyspepsia, overexertion, alcohol or 
sexual abuse, emotional factors, pelvic disorders, and lactation. It is 
attributed, though probably incorrectly, to adenoids. Refractive 
errors may explain some cases, but as Mobius states, "this cause is 
epidemic in the United States." 

Symptoms. — Preliminary symptoms are often absent, although the 
patient may feel depressed, or, in some cases, especially well and 
energetic. They occur in cases in which the sensory symptoms (see 
below) are least marked. Sometimes the pupils are dilated. Most 
attacks develop during the night. 

Aur^:. — In over 50 per cent, of cases, aura? are (a) sensory, as visual 
aura?, a cloudiness before the eyes, sparks, lightning, zig-zag forms y 
etc.; they are most often bilateral, and affect the homologous half- 
fields; taste and smell may be similarly affected; paresthesia may 
occur, usually as hemipara?sthesia ; (b) motor aura? are much less 



MIGRAINE 1227 

common, as aphasia, dysphasia or motor weakness on the contra- 
lateral side; in the very rare form, ophthalmoplegic migraine, there is 
fugitive ptosis, outward strabismus, double vision and a dilated im- 
mobile pupil ; mental aura? are uncommon and not usually pronounced, 
as restlessness, anxiety, confusion, and double consciousness. The 
aura? last for ten or fifteen minutes. 

The Attack. — (a) Headache is the cardinal symptom. As first it is 
usually intense and circumscribed, as over the eye, temple, occiput 
or forehead; then it spreads over one side (hemicrania) , sometimes 
affects the opposite side, or rarely reaches the neck or arm. The pain 
is deep, varies in character, being most often boring, and its intensity 
may attain that of the pain in brain tumor or meningitis. It is increased 
by movement, stooping or lying down. The special senses are hyper- 
a?sthetic but the nerve trunks are seldom tender. The mind is usually 
clear and often acutely active, sometimes there is double consciousness, 
and in rare cases stupor, (b) Nausea follows, often with vomiting of 
undigested food and finally of bile; this is the so-called "bilious head- 
ache. " Feeding and medication are quite impossible in severe cases. 
Vomiting may be attended by hyperacidity or moderate collapse, as 
in sea-sickness, (c) Vasomotor symptoms may be present. The 
spastic type was described by Du Bois Raymond in his own case; with 
pallor, coldness, wide pupils, and retraction of the eyeballs; Thoma 
found the temporal artery sclerotic on the side of lesion, and de Gio- 
vanni noted a marked arcus senilis on the same side. The pulse may 
be slow and tense and the breathing superficial. In the paretic type 
observed by Mollendorf in himself, there are redness, small pupils, 
sweating, and increased flow of saliva or tears. Very rarely is there 
erythromelalgia, oedema or ecchymosis. The paretic may follow the 
spastic symptoms. It is best to regard these sympathetic symptoms 
rather as a result than as a cause of the attack. 

The attack ends in various ways. Relief may come with the vomiting, 
after which the patient frequently sleeps. Sometimes the ending is 
almost critical, with sweating, lachrymation, polyuria or epistaxis. 
The attack lasts from ten to twelve hours ; the term status hemicran- 
icus is used for cases of long duration, or those in which the attacks 
overlap. Though the typical seizure comprizes the aura, lasting 
fifteen minutes, and the headache, lasting ten or twelve hours with 
nausea and vomiting, most attacks are atypical. There is most often 
headache alone, or headache with vomiting; in a few cases the attack 
aborts with the aura, or vomiting exists alone. The aura?, pain, gastric 
and cardiac inhibition, vasomotor symptoms and vomiting can only 
be explained on the assumption that migraine is a functional cerebral 
affection. 

Course and Prognosis. — When the disease has once been established 
in youth, its attacks become more frequent in adolescence and usually 
last until the forty-fifth or fiftieth year. The periodicity, which was 
noted in early cases described by Tissot, Trousseau and Liveing, has 
not been explained. Overwork, worry, menstruation, or change of 



1228 DISEASES OF THE NERVOUS SYSTEM 

routine may precipitate an attack at a regular or irregular interval. 
Attacks may cease during an intercurrent pregnancy, tabes or gout. 
The school of Charcot has emphasized the fortunately rare danger of 
transformation into epilepsy, labyrinthine vertigo, or some psychosis. 
Complete cases are more obstinate and dangerous than the ordinary 
light form. 

Diagnosis. — When there is a history of heredity and development in 
childhood, the full attack is most characteristic. "Sick headache" 
is practically always migraine. In atypical forms there may be diag- 
nostic confusion, chiefly with various forms of headache, which may 
be classified as follows: 

1. Those which result from nervous affections, as (a) cerebral neu- 
rasthenia, in which there is a sense of pressure rather than actual 
headache, and which is often constant, without nausea, but with 
paresthesia, and in location is frontal or usually general, but some- 
times occipital or temporal; (b) hysteria, which is less common, 
(clavus headache, "neuralgic headache"), and sometimes is precisely 
like migraine (Charcot); (c) epilepsy, which some consider as identical 
with migraine; in epilepsy the aura is shorter, and loss of consciousness 
is the most constant symptom; (d) meningitis, which in all types and 
in all cases is early and severe; (e) hydrocephalus, which is often 
severe, especially in acquired forms ; (/) brain tumor, which is constant, 
generalized, often very severe, and sometimes typically hemicranic; 
(g) paretic dementia, in which migraine is frequent; care is always 
necessary when migraine occurs after syphilitic infection. 

2. Those which result from affections of the special senses, as eye 
strain, hypermetropia ; glaucoma, which most often produces frontal 
headache; nasal disease, which may cause involvement of the sinus 
with frontal headache; this form is not periodic and is often relieved by 
iodide, which has no effect in migraine. 

3. Those which result from toxoemia and autotox&mia. (a) Those 
due to acute infections are usually frontal and dull, but sometimes 
occur in other locations and are severe, deep-seated, and increased by 
stooping; in typhoid or malaria they are often frontal or supra-orbital; 
(b) intoxication by alcohol, nicotine, lead, nitroglycerine, and opium, 
and (c) constitutional states, as gout, or arthritis, id) In nephritis, 
they are usually frontal, remittent or continuous, but sometimes 
sharply hemicranic. (e) In gastric affections from toxaemia or con- 
gestion, they are exceedingly common, mostly occipital, but sometimes 
vertical or frontal. 

4. Those resulting from circulatory causes, as from wearing a tight 
collar, repeated coughing, cardiac disease or arteriosclerosis (with 
vertigo), are usually increased by lying down. 

5. Those which result from an&mia, especially from chlorosis, as 
a "tugging" sensation back of the eyes, or frontal or generalized 
headache, are often relieved by lying down. 

Treatment. — Prophylaxis is said to be of little value, but many 
subjects learn to recognize the warnings and avert the attacks, by 



NEURALGIA 1229 

resting or noting unusual mental or physical capacity for work, or an 
unusual appetite, which usher in some attacks. Migraine subjects 
should observe moderation as do other neurotics; moderation in eating, 
especially of meat, in work, in exercise or recreation, in use of narcotics 
or stimulants as coffee or tobacco, and in sexual matters. Immodera- 
tion, indeed, is almost a neurosis in itself. Overwork, hurry, worry, 
and tension must be avoided, and their first manifestations must be 
learned and treated. The extract of cannabis indica gr. \ to \, given 
for weeks or months, after Seguin's plan, is almost the only remedy 
which helps the condition, and then only in some cases; the author 
knows of a dozen cases in which migraine has been benefited or wholly 
relieved under its use. Mobius finds that salicylate of soda, gr. xv, 
in black coffee, given the evening before the attack, often wards it off. 
Nitroglycerine in full doses (Gowers) sometimes aborts it, as may 
washing out the stomach and following the lavage with a saline (Her- 
ter). 

In the treatment of the established attack, bromides constitute the best 
remedy; they are given not only during the attack in the mild type, 
but continuously, as in epilepsy, when the type is severe and frequently 
repeated (Liveing and Charcot). Acetanilide and the kindred coal-tars 
often help the mild forms and may in combination with ergotin, lessen 
the throbbing pain, but soon lose their effect. Morphine should be 
carefully avoided. The stomach sometimes rejects all medication 
which must then be given by rectum. Application of cold to the head, 
hot foot baths and sinapisms to the nape of the neck and epigastrium 
are subordinate helps. 

NEURALGIA. 

Pain in the nerves is only a symptom, usually of an affection of a 
peripheral sensory nerve, although in rare cases centric disease may 
cause peripheral pain, as affections of the cortex, pons, medulla, or 
parts near the thalamus. The pain of neuralgia, in which there is little 
or no organic change in the nerve, and the pains of neuritis may be 
confused. 

Etiology. — (a) Neuralgia occurs mostly in adult life (twenty to sixty), 
and rarely before puberty or after sixty, in which case it is usually 
severe and intractable. (b) The majority of cases occur in women . (c) 
Heredity is an apparent factor in 25 per cent, of cases, especially in 
neuropathic, weakly or gouty families, (d) Debility from exhausting 
conditions, as lactation, anaemia, overwork, sensory fatigue, as from 
eye strain, sexual or other excesses, emotional conditions and trauma, 
may cause it. (e) It may result from toxamiia; (a) acute infections, 
notably influenza, typhoid, especially at its onset, malaria, the causal 
importance of which has been much overestimated, rheumatism ^from 
exposure to cold) particularly of the fascial type, and sometimes 
syphilis may cause it. (b) Alcoholism, diabetes, plumbism, gout, and 
nephritis may produce it; most of these are also causes of neuritis. 



1230 DISEASES OF THE XERVOUS SYSTEM 

differentiation from which may be difficult, (c) Nerve affections as 
sciatica and neuritis, herpes zoster, reflex irritation, as radiated from 
a carious tooth, compression of a nerve trunk by varices, aneurysm or 
neuromata or the root pains of tabes, may cause neuralgia, (d) 
Arteriosclerosis may affect the nutrient nerve vessels; this was first 
asserted by Putnam and Dana, and lately by Thoma and Dehio. 

General Symptoms. — The pain usually presents the following 
characteristics: (a) It is always paroxysmal, with intervals of total 
cessation, or at least of relative relief; intense pain is never constant. 
(6) It recurs either irregularly at intervals varying from hours to months, 
or with surprising periodicity on a given day or hour, perhaps at the 
menstrual period; periodicity is as frequent in non-malarial as in 
malarial cases, (c) It is usually unilateral, is generally constant in 
its seat, at least for a time, and is most often found over the distribution 
of a single nerve, or several nerves, from which it sometimes radiates 
into other regions; if pain is bilateral, it is usually symmetrical. The 
pain may shift from place to place, especially when due to systemic 
causes. It is probable that the spinal cord may be the medium of 
radiation of pain from one region to another and that pain may follow 
the distribution of the spinal segments rather than that of the peripheral 
nerves as in herpes zoster. However, the exact pathology of neuralgia 
is still uncertain, (d) Its onset and cessation are sudden and spon- 
taneous; an imminent attack may be precipitated or existing pain may 
be aggravated by muscular movements, a breath of air or a simple 
touch; the character of the pain is sharp, shooting, stabbing, rarely 
pulsating; if it travels along the nerve trunk its shooting direction is 
usually centrifugal, rarely centripetal; if it is localized it is commonly 
burning or boring, (e) The pain is usually deep, but the skin is very 
hyper aesthetic. (/) The " tender points'' of Valleix (1811), later called 
maximal points by Head, are found in the nerve (50 per cent.) both in 
the attack and the free interval, especially where the nerve emerges 
from the bone or fasciae, lies on hard surfaces, divides or anastomoses. 
The diagnostic value of occasional tenderness over the spine at the 
origin of a nerve (Trousseau's point apophysaire) is overestimated, 
because it occurs in many other conditions. In neuritis, the nerve trunk 
along its entire accessible course is tender, (g) Vasomotor constriction, 
followed by dilatation, is fairly common. (Edema, erythema, blanching 
or falling out of the hair, secretory disturbances, herpes, pigmentation, 
numbness or tingling, trophic alteration of the skin, localized hyper- 
trophies and reflex twitchings of the muscles are much less frequent 
than they are in neuritis. Persistent pain or its etiological factors may 
decidedly reduce the general nutrition. 

Local Clinical Varieties. — 1. Trifacial neuralgia (prosopalgia, tic 
douloureux) is the most important, severe and frequent type, because 
the fifth nerve is most exposed to trauma, compression and infection, 
by way of the eye, nose, and ear. The entire nerve is not usually 
affected, though pain may radiate from one division into another; 
indeed only the secondary branches of a single division may be in- 



NEURALGIA 1231 

Tolved. The general features of neuralgia are present, as already 
described, (a) Involvement of the first branch is the most common 
form; pain occurs over the eye, forehead, and frontal sinus (in which 
the familiar pain is experienced after eating ice-cream) ; it sometimes 
radiates into the second and third branches; there are "tender points" 
over the lower edge of the nasal bone, the supra -orbital notch, less often 
over the supra-orbital nerve, even to the vertex, sometimes over the 
occiput or over the cervical spines; cold, carious teeth, disease of the 
sinus, glaucoma, and errors of refraction (hypermetropia) are causal 
factors, (b) When the second branch is involved, there is pain over the 
side of the nose and cheek from the infra -orbital region to the upper lip ; 
there are "tender points" over the lower border of the nasal bone, the 
malar bone, the infra-orbital foramen, the gums over the canine teeth, 
and sometimes in the hard palate; among other causes due to sclerosis 
is the dental alveolitis in the aged. Diseased teeth may cause neuralgia 
without local dental symptoms; therefore in every severe case the 
dentist should be consulted, (c) Involvement of the third branch is the 
least frequent form; inframaxillary pain, along the lower teeth, tongue, 
chin, external ear and maxillary region; and tenderness over the 
auriculotemporal nerve and inferior dental foramen may occur. In 
old persons the loss of the teeth brings the jaws closer and therefore 
stretches the inf. dental nerve; it is relieved by employing proper plates. 
In severe forms vasomotor symptoms and increased secretion from the 
eyes, nose and salivary glands are usually present. Hyperalgesia is 
usual so that the face cannot endure simple contact, and drinking, 
mastication and wiping the nose cause great suffering. Herpes and 
trophic changes are probably neuritic rather than neuralgic symptoms. 
In rare instances facial spasm, transient reflex ptosis, internal strabis- 
mus or myosis co-exist. Differentiation. In headache and migraine 
there are no tender points; intracranial disease, as tumor or syphilis, 
is usually excluded by systematic examination. The prognosis is 
doubtful in severe forms, which are often lifelong in duration and 
agonizing in degree. 

2. In cervico-occipital neuralgia; there is pain in the first four 
cervical nerves, especially the inferior occipital and auricularis magnus; 
this pain sometimes radiates into the fifth nerve; there is tenderness 
half way between the mastoid and spine, over the parietal eminence 
and over the cervical plexus between the sternomastoid muscle and 
trapezius; this form is rarely primary, is often bilateral, and is less 
intermittent than other neuralgias, which facts are explained by its 
frequent connection, especially with cervical caries and syphilis, and 
also with tumors, meningitis, root disease and affections of the ear. 

3. Phrenic neuralgia is rare, though it sometimes occurs in peri- 
carditis and diaphragmatic pleurisy; it is most often left -sided, with 
pain and tenderness over the insertion of the diaphragm and nerve 
trunk in the neck; movements involving the diaphragm are painful. 
Diagnosis and differentiation are usually uncertain. 



1232 DISEASES OF THE NERVOUS SYSTEM 

4. In ceryico brachial neuralgia, any nerve may be involved, 
but the ulnar and circumflex are especially affected. Pain may 
radiate over the entire plexus and into the chest ; the tender points are 
most often in the axilla, over the shoulder and over the ulnar distribu- 
tion; it is most often confused with neuritis from trauma, compression 
or other organic disease; it may be due to rheumatic arthritis. 

5. Intercostal neuralgia ranks third in frequency after trifacial 
and sciatic neuralgia (neuritis). Pain is felt along the intercostal 
spaces and tenderness over the points of emergence of its three branches, 
over the angle of the ribs, in midaxilla and near the mammary line. 
It is more easily distinguished in the upper than lower interspaces. 
Differentiation may be difficult because of muscular rheumatism in 
which movement is more painful. Peritoneal disease, gastric ulcer, 
spinal caries, aortic aneurysm, and tabes must be distinguished. It 
is most common in gastrohepatic affections, and in neurotic women. 

Herpes zoster is probably an acute specific inflammation of the 
posterior root ganglia, as shown by Barensprung and Charcot and 
later by Head and Campbell. It is mentioned in this connection 
because of the acute pain preceding and associated with the rash, 
which appears after three or four days; the pain is often protracted 
and intractable; the pain on the trunk follows the distribution of the 
spinal segments rather than that of the intercostals. The ganglion is 
the seat of a cellulohemorrhagic exudation and its fibers to the posterior 
column of the cord degenerate. 

6. Lumbar neuralgia is infrequent ; it occurs in the iliohypogastric, 
ilio-inguinaland genitocrural branches, sometimes in the ext. cutaneous, 
obturator and crural nerves. The pain is felt over the iliac crest, in 
the inguinal canal, labium or testes (irritable testicle). 

7. Sacral neuralgia is also infrequent. Coccygodynia is probably 
neuralgic, and occurs mostly in women. The pain is increased by 
sitting, coitus, and defecation; it is obstinate and resists even operative 
measures. 

8. In neuralgia of the feet, there is pain in the heel, which was called 
pododynia by Gross; plantar neuralgia, which is mostly neuritic, 
occurs in acute infections, and in caisson disease. Morton 's meta- 
tarsalgia, which was regarded by him as due to bony compression of 
the fourth metatarsophalangeal nerve, usually occurs in one foot, and 
mostly in women; operation is usually indicated. 

9. Visceral neuralgias are considered under diseases of the heart, 
stomach and kidneys and under hysteria and neurasthenia. Under 
this caption may be given Head's areas of pain referred to visceral 
disease: the organ is first given and following it, is the area to which 
its pain is reflected : Heart: 1st, 2nd, 3rd dorsal segments. Lungs: 1st, 
2nd, 3rd, 4th, 5th dorsal segments. Stomach: 6th, 7th, 8th, 9th 
dorsal; cardiac end from 6th and 7th. Pyloric end from 9th. Intes- 
tines: (a) Down to upper part of rectum, 9th, 10th, 11th and 12th 
dorsal, (b) Rectum, 2nd, 3rd and 4th sacral. Liver and gall-bladder: 
7th, 8th, 9th, 10th dorsal; perhaps 6th dorsal. Kidney and ureter : 



NEURALGIA 1233 

10th, 11th and 12th. The nearer the lesion lies to the kidney, the 
more is the pain and tenderness associated with the 10th dorsal. The 
lower the lesion in the ureter, the more does the 1st. lumbar tend to 
appear. Bladder: (a) Mucous membrane and neck of bladder, 
1st, 2nd, 3rd, 4th sacral, (b) Overdistention and ineffectual con- 
traction, 11th and 12th dorsal and 1st lumbar. Prostate: 10th, 11th, 12th 
dorsal, 1st, 2nd, 3rd sacral and 5th lumbar. Epididymis: 11th and 
12th dorsal and 1st lumbar. Testis and ovary: 10th dorsal. 
Appendages: 11th and 12th dorsal and 1st lumbar. Uterus: (a) In 
contraction. 10th, 11th, 12th dorsal and 1st lumbar, (b) Os uteri. 
1st, 2nd, 3rd and 4th sacral (5th lumbar very rarely). 

Treatment of Neuralgia. — Logically the treatment of the cause 
(q.-v.) should precede that of the symptoms, but practically, pain is 
the prime indication for therapeutic measures. 

1. Local Measures. — Pressure on tender points may diminish or 
abolish pain. As in sciatica, blisters and sinapisms (both of which 
may leave permanent pigmentation on the face), the cautery, local 
heat, acupuncture or injections of water or cocaine may give relief. 
Freezing the skin by ethyl chloride (Richardson, Deddard) often 
gives better results. Menthol, camphor-chloral (equal parts) and 
liniments are of some value (tr. aconiti, tr. chloroformi, tr. belladonna? 
aa 3ij> liniment um saponis 5 1V )- Injections of 1 per cent, solution 
of osmic acid into the nerve trunk are very successful; they were 
recommended by Bennett (1889) and later by Murphy; paralysis 
sometimes results. Massage is often beneficial, for the muscles and 
nerves have common veins, 

2. Nutrition. —A full diet, with milk, and cod-liver oil, and also 
with rest, the Mitchell cure, hydrotherapy and massage, is often 
beneficial, especially with change of climate or surroundings. Alcohol, 
which is always dangerous, is most often indicated in older subjects. 
The beneficial effects of castor oil are often great, probably because it 
promotes elimination. Gouty subjects may thrive on a vegetable diet. 

3. General Drug Treatment. — There are numerous remedies. Iron 
and strychnia, and possibly phosphorus are valuable in anaemic 
subjects. Dana gives strychnine hypodermatically in doses of 30 gr. 
even up to § gr.). Arsenic is excellent in anaemic, malarial and 
degenerative types; quinine is beneficial in non-malarial as well as 
malarial types and in trifacial neuralgia especially, although its value 
is considerably overestimated. Valerian, cannabis indica and bro- 
mides should be given for irritability; salicylates for rheumatism and 
colchicum and cimicifuga for gout; iodides are sometimes of benefit 
to non-syphilitic subjects; full doses of nitroglycerine are frequently 
helpful. 

4. Analgesics. — Acetanilide (gr. v) and the other coal-tars should 
be used first in fresh cases. Extr. cannabis indica? (gr. J) and fluidextr. 
gelsemii (tt# ii to iv) should be administered every three to six 
hours in the less severe cases. In acute febrile or rheumatic cases, 
fluidextr. aconiti (rp^ i to ii) should be given every two hours until 

78 



1234 DISEASES OF THE NERVOUS SYSTEM 

tingling in the mouth or extremities and slowing in the pulse intervenes. 
Liebreich advocates croton-chloral (gr. v), or with care even (gr. xx) 
for several doses. Finally, in severe cases, morphine may be given 
but as far as possible, it should be avoided; sometimes its administra- 
tion is inevitable; though some writers find that it tends to prevent 
recurrence, the pain often develops again, intensified; it should be 
combined with atropine, which may be given alone, as it sometimes 
more permanently controls the pain than does the morphine. 

5. Electrotherapy. — This sometimes relieves the pain, but it more 
often fails. Galvanization with a weak current, which should be just 
strong enough to produce a sensation of burning, and should be applied 
with the sponges warm and with the anode to the painful area, may be 
beneficial, especially in newly developed cases. 

6. Surgical Therapy. — This includes section, resection, stretching, 
twisting or divulsion of the nerves; resection should be tried first, but 
all of these proceedings may fail. In incoercible trigeminal neuralgia, 
the Gasserian ganglion may be extirpated (Hartley, Krause, Keen, 
Cushing), but this operation is severe, and loss of the eye may result. 
Horsley opens the skull and divides the root of the fifth nerve above 
the ganglion, but this also is distinctly dangerous, and Spiller and 
Frazier therefore suggest its division without opening the cranial 
cavity. 

VASOMOTOR AND TROPHIC NEUROSES. 

Vasomotor centres exist in the cerebral cortex and medulla. The 
fibers probably run in the lateral columns of the cord^nd leave by the 
anterior roots. Vasomotor paralysis occurs independently or with 
functional or organic disease. Paralysis of the cervical sympathetic 
may result from trauma, aneurysm, tuberculous apical or glandular 
disease, or disease of the cord. It is attended by redness, rise of 
temperature, pulsation and tortuosity of the vessels, sweating, unrest, 
ringing in the ears and palpitation. In paralysis of the cervical sym- 
pathetic there is pupillary narrowing from the unopposed action of the 
third nerve, slight ptosis, narrowing of the interpalpebral fissure from 
paresis of Miiller's muscle, salivation, lachrymation, and in cases of 
some standing, retraction of the eye and flattening of the cheek. The 
pupil reacts somewhat to light but not to stimulation by pain or 
pinching of the skin of the neck (Mobius) ; the pupil can be widened 
by atropine, but to a less degree than in the normal eye. 

Vasomotor spasm presents converse symptoms, pallor, coldness, 
small vessels, and frequently a sense of tingling or arterial pain. Two 
examples are nervous angina pectoris, and Raynaud's disease; spasm 
(contraction, irritation) of the cervical sympathetic produces wide 
pupils, an increased interpalpebral fissure and exophthalmos. 

Little is known of the trophic nerves, if indeed separate nerves sub- 
serve nutrition. If they exist, they are probably closely related to the 
vasomotor tracts. Trophic changes may be symptomatic of disease of 



VASOMOTOR AND TROPHIC NEUROSES 1235 

the nerves or cord, as in neuritis or nerve trauma, hemifacial atrophy, 
tabes, syringomyelia, and myelitis, under which their special features 
have been already discussed. 

Erythromelalgia was described first by S. Wier Mitchell (1872); the 
term indicates the chief clinical characters, redness and pain in the 
extremities. It is rare, though much more frequent than is shown by 
Rost's series of 40 cases. It occurs mostly between the years of twenty- 
five and forty and is slightly more frequent in males than in females. 
Its pathology is not wholly clear, although Mitchell and Spiller find 
neuritis and sclerosed arteries. The toes (less often the fingers), and 
balls of the toes, are the seat of severe, usually paroxysmal pain, 
swelling and redness; the arteries throb and the veins are engorged; 
the color is sometimes blue. Pain is sometimes experienced in the head 
and neck, and vertigo and muscular weakness may be noted. The 
symptoms occur mostly in warm weather, and generally disappear in 
winter. The clinical course is long, the prognosis doubtful and the 
treatment consists of electrotherapy, cool baths, acetanilide and iodides. 

Acroparesthesia is closely related to erythromelalgia. It was des- 
cribed first by Nothnagel, and F. Schultze (1890) named this very 
frequent affection; its derivation signifies paresthesia of the extremities. 
More than 90 per cent, of cases occur in women between thirty and 
sixty years of age. The etiology is doubtful (stasis or arteriosclerosis). 
Its chief feature is an unpleasant crawling, tingling sensation, some- 
times amounting to actual pain in the fingers or hands, less often in the 
toes or feet. The discomfort is greatest at night and in the early morn- 
ing ; it is peripheral and symmetrical but does not correspond with any 
nerve area. Generally there are no objective findings, other than occa- 
sional vasomotor disturbance or slight sensory blunting. The outlook 
is favorable, the course is chronic and treatment is symptomatic; the 
faradic brush frequently affords relief. 

Spontaneous symmetrical gangrene, or Raynaud's disease was first 
described by Raynaud (1862). Sixty-six per cent, of cases occur in 
women, who are usually delicate, anaemic and neurotic, and most cases 
develop in persons between twenty and forty-five years of age. In 10 
per cent, it is hereditary. Other causal factors are uncertain; exposure 
to cold and dampness, exhaustion, worry and acute infections are some- 
times considered of etiological importance. Occasional co-existence is 
noted with hysteria, neurasthenia, epilepsy, tabes, syringomyelia, 
myelitis, angioneurotic cedema, peripheral neuritis and acute mania. 
Its pathology is not wholly established, but arterial spasm, endarteritis 
and neuritis are said to exist. There are three stages; (a) Local 
ischemia (or syncope), begins with pallor and coldness of one or two 
fingers, perhaps of the entire hand, or of the toes, and is attended by 
numbness or severe pains. The "dead fingers" or toes appear on 
exposure to slight cold or on emotion, and reaction occurs after a 
variable period. The process may not pass this stage, (b) Local 
asphyxia (or cyanosis) develops in the parts involved, at times with 
some swelling or anaesthesia. It is most severe in winter, and chilblains 



1236 DISEASES OF THE NERVOUS SYSTEM 

are regarded as the mildest type of this stage, (c) Local gangrene, 
which is spontaneous, symmetrical and fortunately rare, is the last 
stage. It is dry, sometimes vesicular, and its extent is always less than 
the area of ischsemia and asphyxia. The tips of the fingers or toes dry 
up, fall off and scars mark successive attacks. Less often the tip of the 
nose, ear, buttock, heel, shoulder or abdomen is involved, and very 
rarely the tongue, penis, elbow, or knee. Fever is usually absent. In 
some instances there is severe general disturbance, as fever, chill, 
enlarged spleen, colic, hemoglobinuria, ursemia, stupor, coma, con- 
vulsions, transient hemiplegia, neuritis and spastic retinal vessels. 
The severe or fatal cases occur especially in children. The course is 
chronic and consists of repeated attacks, which often abate in summer. 
Differentiation is usually easy from hysterical gangrene (self-injury), 
diabetic, arteriosclerotic or embolic gangrene, syringomyelia, leprosy, 
ergotism and occlusion by acute arteritis, as in typhoid. 

In treatment, narcotics should be given for pain; warmth and ele- 
vation promote venous return, and nitroglycerine dilates the arteries. 
Cushing advises that Esmarch's constrictor be applied for a few min- 
utes, after which the circulation is restored. In actual gangrene, surgical 
interference should be postponed until complete demarkation develops, 
because the area is usually much more circumscribed than at first 
indicated. 

Acute angioneurotic oedema was first fully described by Quincke 
(1882), although Milton (1876) described " giant urticaria." It occurs 
most frequently between the years of twenty and thirty-five and is 
slightly more frequent in women than in men. Hereditary forms are 
known; 22 cases occurred in 5 (Osier), and 22 cases in 6 (Milroy) 
generations of one family. It is allied to urticaria, erythema nodosum 
and possibly to some forms of purpura, and consists of a circumscribed 
oedema, which is sudden in onset and in disappearance, is tense and 
pale, does not pit on pressure, sometimes causes burning, and appears 
mostly on the eyelids, lips, cheek, tongue, hands or genitalia, some- 
times on the buttocks, pharynx, larynx, lung or digestive tract. It 
sometimes attacks several areas simultaneously. Gastro-intestinal 
symptoms occur in 33 to 50 per cent, of cases, as epigastric pain, vomit- 
ing, colic or diarrhoea (see page 867). Hemoglobinuria, albuminuria 
and polyuria are less frequent. The outlook is good, except for the 
dangerous laryngeal or pharyngeal localization which may cause sud- 
den death. Recurrence is not uncommon, and sometimes occurs with 
considerable periodicity. Treatment is symptomatic and general; 
nitroglycerine has been recommended. Bloodgood employed deep 
incisions with great benefit. 

Twenty-two cases of chronic hereditary trophedema in six genera- 
tions were described by Milroy (1893) of Omaha, and 8 cases in four 
generations by Meige (1898). A firm, pale, painless oedema, chiefly 
below the hip or knee, develops toward puberty, without cardiac, renal 
or apparent local causes. It may appear in the arm and leg of the 
same side, including probably some of the so-called local hemihyper- 



VASOMOTOR AND TROPHIC NEUROSES 1237 

trophies. The first cases recorded were initially thought to be phle- 
bitis. Health and life are not threatened, although treatment produces 
no results. 

Hydrops articulorum intermittens (hydrarthrosis intermittens) or 
intermittent hydrops in the joints, occurs with equal frequency in both 
sexes, and 71 per cent, occurs in persons between ten and forty years of 
age. Its exact etiology is not known. Some cases present malarial, 
gonorrhceal or traumatic antecedents. The knee is usually involved 
when several joints are affected, and in 33 per cent, is alone involved. 
The effusion wholly disappears after two or three days, but it reappears 
obstinately every one to four weeks. There is no fever and usually no 
pain. Treatment is general. 

Scleroderma was described by Lusitanus and Alibert, though Thirial 
(1845) gave the first full account of it. It is a chronic thickening and 
hardening of the skin, followed by atrophy. It is a rare affection, but 
is more common than is generally recognized. The localized form 
usually develops before, and the generalized form after, the twenty-fifth 
year. Seventy-five per cent, of cases occur in women. The causation 
is obscure; erysipelas, trauma, cold, and neuropathic disposition are 
sometimes considered etiological, and association with other neuroses, 
general and vasomotor, is frequent. Anatomically the skin and all the 
contained structures are fibrosed. In the localized form it occurs in 
spots or streaks, which often correspond to the course of given nerve 
trunks or spinal segments. In the general form the body may be 
literally "hide bound." Its distribution in order of frequency is (a) 
the upper extremities; (b) the trunk; (c) the head and face; (d) the 
lower extremities; (e) generalized. The skin is usually first painful 
and sensitive, then reddened and thickened, and finally pale, glossy, 
dry, atrophic and parchment-like. It is rigid and without folds, 
inhibiting the mimetic play of the features. The nose is peaked, 
the lids cannot close over the eyeball and may become everted. The 
mouth is so small as to sometimes necessitate extraction of some of the 
teeth, and rigidity in the neck may render swallowing difficult. In the 
fingers it occurs in 5 per cent, of cases, the condition being known as 
sclerodactylia (Ball). The close skin produces decided deformity and 
loss of function. Sensation is usually preserved, the secretion of sweat 
is usually reduced, and pigmentation and trophic changes in the hair 
and nails are occasionally seen. In some cases it occurs with herpes ; 
this is the herpetiform morphea of Hutchinson. Circumscribed 
atrophy of the bones is said to occur. Only 30 per cent, of cases 
improve, and 15 per cent, recover, whence the outlook is generally 
unfavorable. Treatment is unsatisfactory. Improvement has followed 
administration of salol and inunctions with oil; thyroid extract (Osier, 
Lustgarten, Sachs and Bramwell), especially if used early in the disease, 
may promote recovery. 

Ainhum was first observed by Clark (1860) then by Da Silva Lima 
(1866). It is a chronic affection, usually limited to the great toe, which 
at its plantodigital fold suffers a slow, painless, non-inflammatory 



1238 DISEASES OF THE NERVOUS SYSTEM 

circular constriction and spontaneous amputation. Ainhum is chiefly 
found in the colored races of Brazil, Africa, India and sometimes in 
this country. Its nature is disputed; an ingrowth of the epidermis and 
scleroderma have been thought to be the cause. It is not amputating 
leprosy, as has been claimed. 



VI. DISEASES OF THE MUSCLES. 

1. MYOSITIS. 

Inflammation in the muscles may be single or multiple; it may be 
an independent affection or a secondary one. It may reach the muscles 
by contiguity from adjacent disease, may result from trauma, trichinosis, 
infection with cysticercus, echinococcus, sporozoa (myxo-, sarco- and 
microsporidia), sepsis, puerperal fever, rheumatism, scarlatina, gonor- 
rhoea, syphilis, or erythema multiforme. The muscles are the seat of 
serous or sometimes hemorrhagic or diffuse purulent exudation in 
septic forms, and of fatty degeneration. There is a form, endemic in 
Japan, in which the Staphylococcus pyogenes aureus occurs in pure 
cultures. The muscles are usually friable and sometimes fragmented. 
Polymyositis first described by Wagner (1887), Hepp and Unverricht, 
occurs most often in youth and adolescence and is attended by pain 
especially near the tendons, swelling and often oedema in the muscles, 
the electrical irritability of which is decreased as also are the tendon 
reflexes. The skin may participate, and herpes, erythema, bullae or 
purpura (dermatomyositis) may be present; the infection may involve 
the tissue in which the afferent nerves originate (muscle spindles) and 
topographically a neuritis and myositis may co-exist or coincide {neuro- 
myositis, Senator). In some cases there is arthritis or phlebitis. 
Oppenheim describes a case of dermatomucomyositis with stomatitis, 
iritis and conjunctivitis. The inflammation occasionally reaches the 
tongue, pharynx, larynx, or respiratory muscles, and may even cause 
difficult mastication or swallowing, ptosis or dyspnoea. The systemic 
reaction is usually severe, is marked by fever, chills, sweats, splenic 
tumor, sometimes by angina, bronchitis, albuminuria or leukocytosis. 

The course is usuallv fatal. 

t/ 

Differentiation concerns multiple neuritis (tenderness over the nerve 
trunks, motor and sensory findings); trichinosis (finding trichinae in 
the tender, swollen muscles, increase of the eosinophile cells, and 
digestive symptoms); and the periarteritis nodosa of Kussmaul and 
Maier (q. v.) 

Treatment is symptomatic, and is identical with that of sepsis 
Sweats and administration of aspirin are beneficial. 



MUSCULAR RHEUMATISM 1239 

Myositis ossificans is characterized by a myositis which usually 
develops acutely in the muscles of the neck or back before the fifteenth 
year, and leaves residual foci of infiltration, which gradually calcify. 
The thigh and arm are most severely and permanently affected. The 
process occurs in the strongest muscles and at an age when they develop 
most actively; it may affect many muscles and runs a chronic course, 
perhaps of several decades. One hundred and thirty-four cases are 
recorded (Cahier); there were 101 traumatic cases (Werner, 1904). 
Massage is sometimes beneficial. 



2. MUSCULAR RHEUMATISM (MYALGIA). 

This includes many vague but important affections. It occurs 
particularly in men, after exposure to cold and dampness, and is obvi 
ously promoted by certain occupations. Muscular overexertion, as 
straining and lifting, is frequently a part of the history. Rheumatic 
and gouty subjects are specially exposed and to recurrent seizures. 
Disorders of metabolism or mental as well as physical overwork mark 
some cases. Other forms are, as Leube insists, probably infectious, 
for fever occurs in 33 per cent., and is occasionally followed by endo- 
carditis; muscular rheumatism in this sense does not usually involve 
many muscles, but usually one muscle or a single group. The pain is 
not paroxysmal, as in neuralgia, and is experienced in the muscle or 
reaches it from its tendons or fasciae. In some cases it is apparently 
a mild neuromyositis. Its varieties are; Myalgia capitis, affecting the 
fascia of the head; omalgia, involving the muscles of the shoulder, 
or rheumatic torticollis, which is usually unilateral; pleurodynia, which 
affects the chest muscles, pectoralis, intercostals, and serratus, limits 
respiratory movements and is likely to be confused with intercostal 
neuralgia, pleurisy, periostitis of the ribs, or vertebral disease; lum- 
bago, which involves the lumbar muscles, and is the most frequent, 
painful and obstinate form, causing great pain on movement or on 
efforts of the uninvolved muscles to maintain quiet; it is probably due 
in some cases to muscular rupture, as after lifting. In the abdominal 
muscles and glutei, it may simulate pelvic disease. In treatment, rest 
is urgently indicated, for use of the affected muscles aggravates pain 
and protracts the condition. Involuntary movement is prevented by 
careful strapping with adhesive plaster, especially when there is pain 
in the chest. A hypodermic of morphine, into the muscle, is often 
indicated. 

Deep injection of water into the muscles of the back may relieve 
pain. Ringer's method of acupuncture with long needles which are 
pushed three inches into the back and left there for from five to ten 
minutes is beneficial, but is usually vigorously opposed by the patient. 
Very energetic massage,- with the local application of heat, probably 
gives the best results. The actual cautery, the application of the con- 
stant current, and the use of Tesla's coil give good results. The use of 



1240 DISEASES OF THE XERVOUS SYSTEM 

belladonna plasters gives relief. Gelsenriura, acetanilide and salicy- 
lates often produce no effect, but may instantly relieve certain cases. 

Chronic cases, with vague, fugitive pains which come on with change 
of weather, are treated in the same way — usually without result. 
Confusion with chronic alcoholism, tabes, gout, and diabetes is 
frequent. 



SECTION X. 



INTOXICATIONS. SUNSTROKE 



(A). ALCOHOLISM. 
I. Acute Alcoholism. 

(a) The highest brain centres are first affected. The judgment 
Is first involved (emotion predominating), motility next (as shown 
by the disordered speech, gait and vision), then the lower centres 
(respiratory, circulatory and spinal), (b) The circulation is increased 
and the pulse becomes more rapid, though it is held that alcohol does 
not stimulate the heart. Full doses may make the pulse slow and 
small. The vascular tone is lax and the face is therefore flushed; 
for this reason alcoholics suffer little shock from coincident trauma- 
tism, (c) Respiration is slow, deep, and seldom stertorous, (d) The 
pupils are variable, often dilated or sometimes narrow and reaction- 
less, (e) The temperature may fall markedly, from vasoparesis, and 
usually with some cyanosis and failing of the bulbar centres; Reincke 
states that temperature has fallen as low as 75° ! Involuntary evacua- 
tions occur in the severest cases and there may be subcutaneous hemor- 
rhages. 

Dipsomania is intermittent acute alcoholism, an hereditary psycho- 
sis in which, after intervals of abstinence and of no craving for liquor, 
the patient becomes intoxicated. 

Diagnosis. — The alcoholic breath is usually suggestive but epileptics 
and uremics may drink, and while drunk, a man may have his skull 
broken or suffer an apoplexy. Many mistaken diagnoses result from 
carelessness, but many are unavoidable, and the apparently drunk 
patient should be treated for alcoholism, while other possibilities 



1242 IXTOXICATIOXS. SUXSTROKE 

should be carefully considered. As a rule the patient can be aroused, 
but in "dead drunks" this is not the case, and incomplete coma may 
occur from other causes. The condition of the pupils is not of certain 
diagnostic value, though they are usually dilated in alcoholic, contracted 
in opium and ursemic, and unequal in apoplectic, coma. Stertorous 
breathing is strongly indicative of apoplexy or uraemia. Convul- 
sions following delirium and muscular twitchings are less common 
than in other similar conditions, but at the time of writing, the author 
has a case which showed uni- and then bilateral convulsions. The 
urine rarely contains alcohol, as but one or at the most 5 per cent, 
of ingested alcohol is excreted by the lungs and kidneys. One-third of 
all the fatal poisonings in New York and Berlin are acute alcoholism. 
Treatment. — Gastric lavage is sufficient in most cases. Even the 
convulsions require little attention, but when severe, yield to a few 
whiffs of chloroform. Acute mania yields to a hypodermic of apo- 
morphina? hydrochloras (gr. -J-). Collapse, cold extremities, and 
cardiac and respiratory failure are relieved by hot coffee, strychnine, 
atropine, aromatic spirits of ammonia and local heat, as will be more 
fully outlined under acute opium poisoning (v. L). 

II. Chronic Alcoholism. 

This is less an hereditary tendency toward drinking than a lack of 
character. The constant use of alcohol has varying effects; some 
people can take beer, wine or spirits throughout life without apparent 
injury; in others, even the mildest alcoholic drinks may induce visceral 
alterations, so that as in liver cirrhosis, it would seem that there is 
some other etiological factor; however, alcohol in health is a bad food, 
an injurious narcotic or stimulant, a protoplasmic poison to the paren- 
chymatous organs and arteries, and a check on metabolism. 

Symptoms. — (a) There may be?iervous manifestations. Functional 
changes include the alcoholic tremor, which is a most common symp- 
tom; mental dulness and weakness; nervousness, jumping from 
slight stimuli, irritability, impaired judgment and feeble will power; 
neuralgias and muscular rheumatism. Quinquad's sign is elicited 
by having the patient place his fingers vertically to the examiner's 
hand or body, when a series of jerking shock-like movements are 
noted; Furbringer decides that (i) if it is absent, alcoholism is absent; 
(ii) if it is moderate, there is uncertainty and (iii) if it is marked, in 
3 cases out of 5, the patient is an alcoholic. Of organic nervous 
manifestations, multiple neuritis is the most common; it may result 
from small amounts of alcohol, when there is a coincident metallic 
poisoning; it is much more often a promoting factor than an actual 
cause of paretic dementia; epilepsy may result from alcoholism; 
hemorrhagic pachymeningitis, chronic leptomeningitis, acute polio- 
encephalitis, degeneration in the anterior horns, or Clark's columns, 
degeneration of the cerebral nervous tissue and slight optic neuritis 



DELIRIUM TREMENS 1243 

may be more or less direct sequences. (6) The circulation is affected. 
Arteriosclerosis often develops with its train of sequences, cardiac- 
hypertrophy and dilatation, angina pectoris, cerebral softening or 
hemorrhage, (c) Chronic bronchitis and emphysema are frequent 
collateral findings. There may be chronic pharyngitis and laryngeal 
thickening, (d) The digestive organs are involved. Alcoholic gastritis 
(q. v.) is common; the morning vomiting (vomitus matutinus) is 
quite characteristic, and is quieted only by another dose of its cause. 
Beer drinkers usually have large stomachs. Alcoholic cirrhosis has 
been already discussed; fatty degeneration, arterial congestion and 
hypertrophy may antedate or accompany cirrhosis. Beer drinkers 
have lax bowels, while consumers of spirits are constipated. Hemor- 
rhoids are common, (e) The kidneys undoubtedly suffer. Dickinson, 
Formad and Pitt think that renal disease is less common than is usually 
believed; Formad and Pitt found that the kidneys were hypertrophied 
without other change in 43 per cent. As in cirrhosis, several factors 
may be necessary to produce indurated kidneys. (/) Metabolic mala- 
dies, as gout, obesity, and, according to Strumpell, some forms of 
diabetes may result from chronic alcoholism, (g) The skin frequently 
presents the acne rosacea, a very common but not, as Trousseau says, 
an "indelible stigma/' The vessels of the nose, cheeks and often of 
other parts are suggestively dilated; the conjunctiva? are injected and 
the eyes water. 

Prognosis. — The prognosis is unfavorable, both from the stand- 
point of curability and complications. English life insurance com- 
panies estimate that the risk is 25 to 43 per cent, less in abstainers than 
in alcoholics. The general resistance is lowered, thus favoring infec- 
tions, as tuberculosis, and raising greatly the death rate, most notably 
in pneumonia. Twenty per cent, of suicides are alcoholics. The 
offspring of inebriates are disposed to numerous nervous affections. 

Treatment. — Treatment consists of correction of the habit and care 
of the complications, the latter of which have, in great part, already 
been considered. The cure of the habit is largely personal. Its 
prophylaxis is better than its cure. No person, however intellectual 
or strong-willed, can safely drink with any regularity. Institutional 
treatment is generally necessary. The vomiting should be treated in 
accordance with instructions given under acute and chronic gastritis; 
lavage is probably the most reasonable measure ; a mixture of bismuth 
(see Typhoid, Vomiting) and small doses, (n£ i to ii) of Fowler's solu- 
tion and large ones of tr. nucis vom. (ttjj x) are valuable just before the 
administration of hot milk with tr. capsici, tt# x. Hyoscine (gr. ri©) 
should be given two or three times at 3 hour intervals, chloral hydrate 
(gr. x) and sod. bromide ( 5 ss) for three or four doses, before bedtime, 
or sulphonal (gr. xx) in hot milk before bedtime, in order to induce 
sleep. Atropine (gr. th) and strychnine (gr. &) four or six times daily, 
hypodermatically, quiet the nervousness, which occurs in the first days 
of abstinence. Sipping ice-water, sucking lemons, or drinking water 
with tr. quassise, may satisfy the desire to " drink something. " Cocaine 



1244 INTOXICATIONS. SUNSTROKE 

and morphine should be avoided, lest a substitution or succession of 
habits develop. Relapse is very common. 



III. Delirium Tremens. 

Delirium tremens (mania a potu) is an acute accident of chronic 
alcoholism, and almost never follows an acute debauch in an other- 
wise temperate individual. It was noted among sailors by Sutton of 
Greenwich in 1813, but was probably best described by Ware of 
Boston in 1831. Sixty-six per cent, of cases occur in men, while multi- 
ple neuritis is more common in women (Gowers); most victims are 
between thirty and forty years of age. The stronger spirits, rather 
than beer or wine are the cause of delirium tremens as they are of 
alcoholic convulsions. It may be precipitated by trauma, mental shock, 
the shock of onset of an acute infection, or by sudden failure of the 
stomach to digest and assimilate food. 

Symptoms. — The symptoms develop with restlessness and insomnia, 
which renewed drinking fails to allay; for a day or two the mind wan- 
ders, but can be brought back to realities. The patient may be face- 
tious, but is soon disturbed by horrible hallucinations. There is 
"great versatility of ideas" in delirium tremens. The patient talks 
volubly, turns suspiciously to the head of his bed, drives his horses 
vigorously, and brushes away the vermin from the coverlet. He at 
first knows that the bugs and snakes are unreal, but they soon become 
actual torments, so that unless watched he will leap from the window 
after waiting for his opportunity. The pulse is rapid and soft, the 
tongue is tremulous and is coated white, the urine is scanty, and sleep 
is constantly absent. There may be moderate fever, 101 to 103°, 
which some attribute rather to complications. 

Diagnosis and Prognosis. — The diagnosis is rarely uncertain. 
The chief danger of error is in overlooking coincident causal trauma 
and infection, as pneumonia. In heavy and constant drinkers, a 
delirium may be delirium tremens or an "associated delirium," as 
from apical pneumonia. 

The outlook is always uncertain. The early convulsions are of no 
great moment (Gowers). The prognosis is determined by the pulse, 
the general nutrition and complicating alcoholic or other lesions. 
Rigidity of the muscles of the neck is ominous (Putnam), and indicates 
oedema of the brain. The average mortality is 15 to 20 per cent., but 
varies as the affection is (a) uncomplicated (relatively good prognosis), 
(6) associated with other affections (grave outlook) or (c) occurs in the 
aged or debilitated (probably fatal outlook). Recurrence after recov- 
ery is frequent, and 27 attacks in one case have been recorded. In 
fatal cases death usually results from exhaustion and heart failure; 
the tongue becomes dry, the delirium constant, and the skin cold and 
clammy. The autopsy shows oedema of the brain ("wet brain"), 



OPIUM POISONING 1245 

degenerative changes in the brain .and cord (Bonhoeffer), arterial 
alteration (Collins), and hypostasis of the bases of the lungs. 

Treatment. — (a) The patient should be kept in bed and watched 
constantly lest he escape. Strapping the ankles and wrists and confining 
him by a straight jacket is a harsh procedure, and invites trauma to the 
hands and feet, but is inevitable in cases where the family is indulgent, or 
when the nurses are negligent, (b) Withdrawal of alcohol is usually 
advocated but is a severe measure; the continuance of moderate doses 
seems to hold the pulse steady, and favors the digestion and is, in the 
author's belief, indicated, (c) Sleep is induced with great difficulty 
and as Ware first pointed out, comes when the disease runs its course. 
Excessive medication should be avoided. Sod. bromide (5 SS )> tr. 
capsici (tt# v) and whiskey (3 n )> m hot peptonized milk should be 
given every (two or) three hours, by mouth if possible, or by the nasal 
catheter, for nutrient enemata are difficult to give and are seldom 
retained. Chloral is always dangerous in inveterate alcoholism. 
Hyoscine with strychnine may be beneficial (v. s.) Morphine should 
be given only by the hypodermic method, for its absorption can then 
be measured; it was formerly given to excess. Protracted warm 
baths may quiet the patient, but they are hard to administer. In 6 
cases in which the violent delirium became ominous, the writer has 
etherized the patient, and in 3 instances with excellent results, though 
he does not advocate its wide use. (d) The circulation should be treated 
as in pneumonia. Large doses of digitalis are not indicated; they are 
tolerated only because they are not absorbed, as the original treatment 
by digitalis proves; it is based on the fact that a nurse by mistake 
gave a toxic dose of digitalis; the patient improved and the " digitalis 
treatment" was thus instituted, (e) Cold affusions upon the neck and 
chest are recommended by Broadbent. 



(B). OPIUM POISONING. 
I. Acute Poisoning. 

This is important chiefly from a diagnostic standpoint. In the 
second stage it is strongly characterized by profound sleep, dry, 
flushed skin, narrow pupils, slow, strong "digitalis pulse" and slow 
deep stertorous breathing. The third or terminal stage is different; 
the skin becomes cyanotic and clammy, the narrowed pupils may 
dilate, the pulse become weaker (though the heart centers live after 
the other bulbar centres have died), respiration halts, and is very slow. 
Mistakes in diagnosis are made by attributing undue importance to 
the "pin point" condition of the pupils. Morphine may be detected in 
the stomach washings and in the urine. 

Treatment. — This consists of (a) mechanical evacuation by repeated 
gastric lavage, (b) Chemical antidotes, such as large amounts of 
tannic acid, should be given with the lavage, and removed as the 



1246 INTOXICATIONS. SUNSTROKE 

tannates formed may dissolve; 1 to 1,000 permanganate of potash 
(Moor, of New York) may be given by mouth or hypodermatically. 
(c) Respiration must be sustained by walking the patient (the ambul- 
atory treatment), but fatigue must be guarded against; phrenic 
faradization is indicated, but care is necessary lest too strong a 
current produce paralysis instead of stimulation; strychnine plus 
atropine may be given hypodermatically, but the total dose of atropine 
should not exceed gr. 3 X o to 20 ; pulling slowly and rhythmically on the 
tongue may help respiration; Sylvester-Hall's artificial respiration and 
oxygen inhalation may be used, id) The heart should be stimulated 
by coffee, strychnine, heat and digitalis. 



II. Chronic Morphinism (Morphinomania). 

The use of morphine for pleasure only, so common in Asia, is rare 
with us. The habit is contracted by its use for insomnia or for 
mental or physical pain. Forty-seven per cent, of morphine victims 
are said to be physicians; women and — in Germany — officers rank 
next. It may be taken for years without mental or physical deteriora- 
tion, but morphinists are usually less happy, as increase in the daily 
dose becomes necessary and the half -oxidized alkaloid produces symp- 
toms (v. i. Treatment) which are only allayed by larger doses. Mor- 
phine acts as a nerve poison. The victim becomes restless and irritable 
without his dose. The mental and moral attributes are anesthetized 
and there is a " moral insanity." The patients lie by choice, neurotic 
symptoms are common, muscular and mental asthenia develop, the 
pupils are contracted, the sweat and saliva are decreased, the appetite 
fails, the skin becomes sallow, itchy and dry, the hair coarse and gray, 
constipation is usual, and slight ataxia may develop. 

Prophylaxis. — Physicians should not give opiates too freely. When 
they are administered for severe pain the habit is less often contracted 
than when given to neurotics. At least 70 per cent, of cases relapse 
after a cure. 

Treatment. — Treatment is almost impossible without (a) institu- 
tional confinement, which must of course be voluntary, (b) The 
morphine may be withdrawn abruptly, rather suddenly or very grad- 
ually; the second method is the best, stopping the morphine entirely 
in four to seven days. Its withdrawal is attended by awakening 
of dormant anaesthetized functions; there is' at first paroxysmal 
yawning and sneezing; roughening of the voice, paresthesia, neural- 
gias especially in the legs, clammy skin or rapid pulse, wide pupils, 
tremor, sexual excitement, extreme irritability, vomiting, colic and 
diarrhoea also occur. The symptoms were attributed by Marme to 
di-oxymorphine poisoning, the antidote to which is morphine; Hitzig 
believes that they are largely due to hyperchlorhydria, for the gastric 
nerves under the influence of morphine secrete little hydrochloric 
acid; relief is obtained by washing out the stomach with a solution of 



LEAD POISONING 1247 

Carlsbad salts. The patient will obtain morphine if possible, (c) 
The patient should be kept in bed for a week to obviate vasoparetic 
cardiac collapse, (d) Symptomatic treatment is indicated (i) by the 
collapse (aromatic spts. of ammonia, ttj? xx, strychnia gr. ?fe, heat); 
(ii) by nervousness (warm baths, sodium bromide in doses of one 
dram every four hours); (hi) by the insomnia (hyoscine gr. t !<j every 
two hours for two to six doses, sulphonal or trional, gr. xx); (iv) of 
the gastralgia (gastric lavage with alkaline salts); (v) by diarrhea and 
colic (as in enteritis, but vegetable astringents, large doses of bismuth, 
and no opiates should be used) ; (vi) by neuralgia (acetanilide, gr. v, 
fluidextr. gelsemii., ngiii). Whatever treatment is instituted, alcohol- 
ism, chloralism, bromism or cocainism should not be substituted. 



(C). LEAD POISONING. 

Etiology. — Plumbism or saturnism is very common, and its im- 
portance is daily increasing, (a) Industrial plumbism is very common. 
Workers in white or red lead factories usually acquire the disease. 
Miners of the metal generally escape, but smelters of lead ore, and 
even animals and birds near the furnaces, are frequently affected. 
Painters, plumbers, glaziers, less often tinners, printers, cameo polish- 
ers, cartridge makers, etc., may be affected, (b) Accidental con- 
tamination of food or drink may occur. Poisoning may result from the 
action of acids in canned foods on the tin or solder, as in cans of 
sardines; wine or cider may become poisonous in the same way, as 
happened in Devonshire, and in Poitou (colica pictonum). Chromate 
foil, covering hams or candy, rubber nipples, bullets in pickled game, 
bread ground in lead vessels, chromate used to color buns (D. D. 
Stewart's report of the fatal Philadelphia epidemic), Seltzer or other 
charged waters, wine, and eau de vie sweetened or cleared with litharge, 
are a few of the many subtle causes of saturnism. Drinking water 
conveyed through lead pipes is generally protected by the deposit of 
lime and other salts, but poisoning is possible when the water is ex- 
ceptionally pure or soft, thereby depositing little lime in the pipes, 
or when it is saturated with organic matter or collected from lead 
roofs, (c) Less frequent sources of plumbism are in the environment, 
and in such things as hair-dyes, powders or cosmetics, linen, freshly 
painted walls, candles, sealing wax, brightly tinted toys, false teeth, 
and thread, {d) Therapeutic and criminal plumbism is rare; it may 
result from the acetate of lead when given internally or externally, 
and from impure subnitrate of bismuth; its criminal use is very un- 
common, (e) Predisposing factors are alcoholism, age (it occurs most 
often in persons from thirty to forty) and sex (75 per cent, of cases are 
females, Oliver). Susceptibility varies greatly; plumbism may cause 
death within a week, or may not develop until after forty-two years of 
work in the metal (Tanquerel des Planches). Absorption of lead 
usually occurs (i) by the digestive mucosa; most of the metal is pre- 



1248 IXTOXICATIOXS. SUXSTROKE 

cipitated by the albumin of the food and eliminated without absorption; 
(ii) by the respiratory mucosa, by inspiration as dust in white lead 
factories; or (hi) by the sound or diseased skin (cosmetics) or even 
the conjunctiva or vagina (lead douches). It is eliminated chiefly by 
the urine; Putnam stated that he found lead in 25 per cent, of 150 
persons who had no evidence of plumbism; the liver and alimentary 
mucosa eliminate smaller quantities. 



I. Acute Poisoning. 

This is uncommon, though it may occur from therapeutic, criminal 
or professional causes. Its symptoms are (a) gastro-intestinal; a 
styptic burning taste occurs in the mouth, thirst is present, there is a 
lead line on the gums in some cases, though less than in chronic poison- 
ing, nausea and vomiting sometimes of white lead chloride, abdominal 
colic, retraction of the abdomen, diarrhoea with black (lead sulphide) 
or bloody movements, or sometimes constipation. On postmortem 
examination, the catarrhal gastro-enteritis may be wrongly considered 
a postmortem change; white spots may be seen (Orfila's spots). 
The symptoms may be (b) circulatory; the pulse may be slow (40 
to 50) and irregular; anaemia, cyanosis and collapse may occur; (c) 
they may be nervous; vertigo, stupor, delirium, neuralgia, cramps, 
convulsions, and even cerebral and peripheral paralysis may develop; 
(d) nephritis with suppression of urine may develop. 

Treatment consists of full doses of sodium and magnesium sul- 
phate, in order to precipitate an insoluble lead sulphate, and to remove 
it, demulcent drinks (eggs and mucilages), opium for pain, and 
cardiants. 

II. Chronic Poisoning. 

Symptoms. — (a) Colic is the most common symptom; it occurred in 
88 per cent, of Tanquerers 1,390 cases. It is due to local deposit of 
lead in the intestines (muscles or mucosa), spasm of the bowel, changes 
in the nerves or angiospasm. It may develop early or late; it may be 
preceded by malaise, lumbago or pain in the legs, or may be brought 
on by alcoholic excesses. It is a colic accompanied by constipation 
(dry colic), rarely by diarrhoea; it is umbilical, whence it spreads 
over the abdomen, perhaps to the legs or scrotum; it is relieved by 
pressure, though sometimes the abdominal wall is* hypersesthetic; 
sometimes vomiting and absolute constipation may simulate obstruc- 
tion, and in one case the author observed intussusception as a result of 
lead poisoning. There is no fever, the pulse is small and hard (Riegel) 
and the urine is scanty. Without treatment colic is protracted; its 
relief is usually marked by a bowel movement. Relapses are very 
frequent, (b) The gingival lead line, which is present in over 90 per 
cent., is a gray-black line, 2 to 3 mm. wide, which is seen most clearly 



CHRONIC LEAD POISOXIXG 1249 

on the lower gums and is due to deposition from the blood of lead 
sulphide, precipitated by the sulphuretted hydrogen of the tartar. 
The coincident anaemia brings it out very clearly. Similar deposits 
may occur under the buccal mucosa opposite the molars. It is very 
frequently mistaken for tartar, which occurs on the teeth, sometimes 
for the black carbon line seen in miners, or rarely for the silver line in 
argyria. (c) Other digestive symptoms are coated tongue, foetid 
breath, parotitis, saturnine dyspepsia and rarely icterus. Test meals 
show lactic acid and no HC1 (Sailer and Speese). (d) Anaemia is 
very frequent in the "lead cachexia." The haemoglobin and erythro- 
cytes decrease moderately; the red cells show basophilic granules 
(Grawitz) and quite commonly nucleation, even in mild cases (Cad- 
walader, 1905). The leukocytes may be increased, (e) The heart 
and vessels are affected. The heart is very often hypertrophied, as 
is evidenced by a loud second aortic tone and aortic regurgitation of 
atheromatous origin; the arteries are often sclerosed, occasionally 
causing angina pectoris, frequently myocarditis, irregular heart action 
and perhaps some of the brain symptoms (v.i.). The asthma saturni- 
num is probably cardiac or uraemic. (/) The kidneys are often sclero- 
tic, as a result of the elimination of the metal. It is said that the change 
does not begin around the vessels but in the tubules, which are the 
seat of a necrosing deposit of carbonate of lime. Nephritis, gout and 
plumbism may co-exist (v.s.). (g) Nervous manifestations may 
develop. Peripheral degenerative neuritis occurs in 7 per cent., 
usually as a later symptom. About one-tenth of these cases have not 
had colic. It is characterized by the paralysis of muscles with the same 
function, by muscular atrophy and cramps, tremor, cutaneous hyper- 
esthesia, neuralgia, arthralgia (55 per cent.), myalgia and by varying 
degrees of reaction of degeneration (v. Multiple Neuritis). The 
musculospiral type, "wrist drop," is the most common and is bilateral; 
the supinator longus (a flexor) and the small extensor of the thumb 
escape involvement; tenderness and anaesthesia are rare. Gubler's 
tumors are swellings of the extensor tendon sheaths and are due to 
backward dislocation of the carpus or perhaps to a trophic change; 
they are hard, ovoid, indolent, seldom painful or larger than a pigeon's 
egg, and regress with the paralysis. A second but rare form is the 
brachial, involving the deltoid, biceps, brachialis anticus, and supinator 
longus, rarely the pectorales. A third rare type is the Aran-Duehenne, 
which is especially observed in tailors (Mobius), and involves the 
small muscles of the hand, the thenar and hypothenar eminences; it 
resembles that of chronic anterior poliomyelitis (which indeed has 
been found in a few cases at autopsy). A fourth type, the peroneal, 
involves the peronei and toe extensors; according to Tanquerel, but 
13 per cent, of lead palsies affect the leg. Lastly, rarer types may 
involve the larynx, vagus, and face; generalized paralyses, either slow 
or rapid like Landry's paralysis, are very rare; primary muscular 
atrophy may occur, is most often of the Aran-Duchenne type, and 
shows fatty and fibroid muscular changes. 

79 



1250 INTOXICATIONS. SUNSTROKE 

Cerebral forms (encephalopathia saturnina) occur in 5 per cent., 
they are often preceded by headache, colic, and insomnia, and are 
attended by amaurosis, limitation of the visual field, or other dis- 
turbance of the special senses, retinitis albuminurica or saturnina 
(with inflammation, engorgement and possibly ultimate atrophy), 
and paralysis of the eye muscles. The most frequent type is the 
delirious encephalopathy, which is variable or mobile in character, 
and sometimes resembles delirium tremens; the next type is the con- 
vulsive (epilepsia saturnina) which occurs without aurse, is usually 
generalized, often fatal, and is always to be considered when epilepsy 
develops in an adult; the third type is the comatose. Hysteria fre- 
quently occurs with plumbic encephalopathy. Neglected or un- 
recognized cases may become dements (pseudodementia paralytica 
saturnina). Deposit of lead in the protoplasm of the brain is the usual 
cause; sometimes the cerebral symptoms are arteriosclerotic (as 
hemiplegia) or ursemic. 

Lead-poisoning is usually recognized (a) by the etiology, (b) by the 
lead line, (c) by lead in the urine, (d) by colic and (e) by wrist-drop. 
In a case of long coma with choked disk, in the Cook County Hospital, 
no cause was found, until after a second examination, the lead line was 
seen. The man was a barber, who regularly dyed the hair of a number 
of people, and probably absorbed the lead through his hands. 

Prognosis. — The acute forms are more favorable. Vascular and 
renal changes are largely incurable. Atrophic paralyses are serious. 
The wrist-drop usually regresses, though it is sometimes permanent. 
Coma,- convulsions and other cerebral symptoms are serious; about 
25 per cent, of cases die, and after apparent recovery, mental degen- 
eration may develop. 

Treatment. — (a) Prophylaxis should be observed. A mask should 
be worn in white-lead factories to avoid inhalation of lead dust ; workers 
are careless and poisoning is frequent despite precautions. Painters 
and others may often avoid poisoning by carefully cleaning the hands 
and nails before eating, (b) Lead colic is treated by hypodermic 
injections of morphine and atropine to control pain and spasm. Riegel 
uses nitroglycerine for the supposedly causal spasm of the vessels. 
Spts. of chloroform (tt# xx) with other aromatics may be given by 
mouth, (c) The constipation, and removal of any lead salts, unab- 
sorbed in or excreted by the alimentary mucosa, necessitate catharsis. 
Full doses of castor oil (5iv or more) with paregoric (5i) evacuate 
the bowels, and relieve pain and spasm; sodium and magnesium 
sulphates purge and coincidently precipitate the lead as an insoluble 
sulphate, (d) In order to eliminate the lead from the tissues, with 
the protoplasm of which it has united, potassium iodide, which breaks 
up this union and eliminates the metal, should be given. In acute or 
severe chronic cases it should be given with care, for it transforms the 
fixed tissue metal into free metal in the circulation. Nevertheless, 
small doses of potassium iodide (grs. iii to v ) should be given, and some 
writers obtain even better effects from potassium bromide (grs. v to x). 



FOOD POISONING 1251 

Warm baths and pilocarpine (gr. J) promote excretion by diaphoresis, 
and plenty of water stimulates the renal elimination, (e) Iron (not 
arsenic) should be given for anaemia. (/) For treatment of neuritis, 
see Multiple Neuritis. 



(D). ARSENICAL POISONING. 

Acute poisoning has been considered under pernicious anaemia. 

Chronic Poisoning. — (a) Criminal poisoning is of great medico- 
legal importance, as in the unfortunate Maybrick case, (b) Poisoning 
by reason of occupation is uncommon, (c) Therapeutic poisoning 
is not common, but may occur in chorea, leukaemia, and pernicious 
anaemia, (d) Most cases are accidental. The dyes in garments, toys, 
glazed paper used in kindergartens, wrappers, artificial flowers, and 
wall paper are important sources of intoxications. The action of 
moulds (pencillium and mucor) may liberate volatile arsenical gases. 
Contaminated glucose used in beer caused the Manchester epidemic. 
Arsenic is absorbed by the lungs and alimentary tract, and is chiefly 
eliminated by the kidneys, which may degenerate. Putnam found 
arsenic in the urine of 30 per cent, of persons who showed no other 
symptoms of arsenical poisoning but in this connection it may be 
remarked that arsenic is widely found in plants, sea water and springs. 
Smaller amounts are eliminated by the bowel, milk, and other secre- 
tions. 

The symptoms are (a) gastro-intestinal, as dry throat, vomiting, 
purging, or colic; the stools may be like "rice water" and contain 
flecks of mucus; and (b) respiratory, as dry cough or chronic bronchi- 
tis, (c) Emaciation, weakness, fever and anaemia may occur, (d) 
Cutaneous symptoms, as erythema, keratosis, pemphigus, herpes and 
brown pigmentation and (e) nervous manifestations, as weak memory, 
vertigo, headache and multiple neuritis may develop. The neuritis 
has the same general features as the saturnine form, save that sensory 
changes are more frequent, and the legs are more often affected than 
the arms; paralysis of the peronei and foot extensors causes the 
"steppage" gait. The small muscles are less often affected than in 
plumbic or alcoholic neuritis; paralysis, ataxia, sensory and trophic 
disturbances and the reaction of degeneration occur as in other neuri- 
tides. Treatment is that of lead poisoning or neuritis. 



(E). FOOD POISONING. 

Bromatotoxismus (Vaughan) exists in several forms: 

I. Meat Poisoning (Kreatoxismus). — Sausages and head cheese 

are more dangerous than beef or mutton. Sausage poisoning (botulism 

or allantiasis) was known in Germany a century ago. Van Ermingen 

has isolated an anaerobic organism, the Bacillus bat ul in us; it contains 



1252 INTOXICATIONS. SUNSTROKE 

spores, is flagellated and mobile and grows only on alkaline media at 
a low temperature (18 to 25° C) ; it is a saprophyte and causes symptoms 
by its toxins only, which are not destroyed by the gastric juice. Meat 
may seem to be normal to the taste and smell and yet contain pto- 
maines; their nature is still undetermined though Cobert considers 
them promatropin. Canned meat has often caused severe symptoms. 
In one instance botulism was caused by eating salad (Collatz). The 
symptoms of botulism appear in twelve to forty-eight hours, with nausea, 
vomiting and sometimes diarrhoea. Paralysis of the soft palate, larynx 
and oesophagus rapidly develop, and somewhat later paralysis of the 
bowel, mydriasis, ptosis, disordered vision, adynamia and weak heart 
action; the sensorium is clear and fever is unusual. The mortality 
ranges between 20 and 50 per cent. ; death occurs in four to ten days 
and the autopsy shows parenchymatous degenerations and ecchymoses 
but especially degeneration of the ganglionic cells, as those of the 
vagus or oculomotorius; if the patient survives, convalescence is 
established only after months. In the Wellback cases, Ballard noted 
as early symptoms, headache, chilliness or rigors and pains in the chest 
or back. 

The symptoms of other forms of meat poisoning are either those of 
toxcemia (the typhoid type) or g astro-intestinal inflammation (cholera 
type); the typhoidal symptoms, which appear after an incubation of 
four to six days, are fever, status typhosus, and even roseolse; the 
choleriform symptoms, which develop in two to twelve hours, are 
vomiting, incessant purging, watery stools, clammy skin, collapse and 
cyanosis. Mild or rudimentary forms occur in most epidemics. 

Treatment is unsatisfactory. Early gastric lavage and purgation are 
indicated; calomel followed by castor oil is the best aperient. Other- 
wise symptomatic medication as in cholera or typhoid is indicated; 
champagne, strychnia, hypodermatoclysis, and opium may be given. 
The resemblance of botulism to the diphtheria toxins has suggested 
the use of antitoxine; its effects in animals have been remarkable, but 
to the author's knowledge it has not been used in man. 

II. Poisoning by Milk (Galactotoxismus) and Cheese (Tyrotoxismus) 
— The former produces symptoms analogous to those of the infantile 
affections of the bowel, as vomiting, bloody diarrhoea, fever, and 
collapse. In cheese poisoning Victor C. Vaughan has found tyrotoxi- 
con and other more frequent toxins, which are probably albumoses. 
Similar ptomaines were found by him, by Novy and by Perkins in 
re-frozen ice-cream, and custard. In Norway where tyrotoxismus is 
most prevalent, the colon bacillus has been repeatedly found. Home- 
made cheese is more dangerous than the factory product. Various 
forms of toxaemia result; some are cholera-like, and others resemble 
belladonna poisoning. Treatment is that of kreastoxismus. 

III. Poisoning by Fish (Ichthyotoxismus) and Shell Fish (Mytilo- 
toxismus). — (a) Ichthyotoxismus, described by Comby (1827), may 
be caused by poisonous fish or poisonous glands in certain fish, as the 
roe or testicles, the muscular parts being harmless; the barben in 



FOOD POISONING 1253 

Europe, and the tetrodon in Asia are poisonous (v. Beri Beri). The 
poisoning due to putrefaction is more common. Paralytic symptoms 
are most frequent. (6) Mussel poisoning (mytilotoxismus) may cause 
dyspeptic symptoms in mild infections and cholera-like symptoms or 
symptoms of belladonna poisoning in severe forms. Rashes are com- 
mon. Brieger isolated a mytilotoxin, which is found largely in the liver. 
The danger lies in placing mussel- or oyster-beds near river mouths, 
so that they feed on poisonous excreta. In restaurants, certain glands 
near the heads of lobsters, which are considered toxic, are carefully 
excised. 

IV. Grain poisoning (Sitotoxismus). 

1. Ergotism, which was described by Thuillier (1830) and carefully 
studied by Tiiczek (1879), results from eating grain mixed with the 
ergot fungus (claviceps purpurea). Ergotized grain is found largely 
in bad harvests, resulting from wet springs and hot summers. Epi- 
demics have occurred in Europe, and sporadic cases are not rare. 
Acute ergotism, with digestive symptoms, colic, cyanosis, weak heart 
and generally lethal outcome is less common than chronic ergotism, of 
which two forms exist; the first is the convulsive form, attended by 
paresthesia, lightning pains, headache, delirium, melancholy, demen- 
tia, muscular relaxation and muscular spasms, either as generalized 
epileptiform attacks, or as local contractures (flexion of the arms and 
extension of the toes and feet) ; it is said to result from the alkaloid 
cornutin. The second form is the gangrenous, due to sphacelinic acid 
and marked by localized gangrene, usually in the phalanges, and 
less often in the tips of the ears and nose. Chronic ergotism is char- 
acterized by a number of symptoms which suggest tabes, as lightning 
pains, ataxia of station and movement, and lost knee jerks; and in 
five autopsies Tiiczek and Siemens found degeneration with, later, 
sclerosis of the posterior columns; degeneration in the anterior cornua, 
and minute foci of softening or hemorrhage also occur. The clinical 
course is chronic, and death is frequent from convulsions or cachexia. 

Treatment includes avoidance of diseased grain, and symptomatic 
therapy; opium should be given for convulsions, and nitroglycerine 
for gangrene. 

2. Pellagra or maidism is a chronic nutritional and toxic affection, 
due to the use of maize which has been improperly stored, or is decayed, 
unripe, or infected with the aspergillus. An alkaloid (pellagazein) 
is thought to develop. Pellagra is endemic, chiefly in Italy, France, 
Spain, Hungary and Mexico. It occurs among poor farmers. There 
are three stages; the first consists of the vernal erythema, which is 
followed by exfoliation and sometimes by suppuration; dyspepsia and 
diarrhoea may develop; mild cases may recover, or may pass into the 
second stage, in which headache, pain in the back and muscular spasms 
occur, but the most characteristic symptom is the ataxic paraplegia ; 
autopsies reveal a posterolateral sclerosis, sometimes with atrophy 
of the anterior horns, leptomeningitis, and variable brain findings. 
The third stage occurs after repeated attacks and is usually incurable; 



1254 INTOXICATIONS. SUNSTROKE 

cachexia, epilepsy and dementia develop; it is said that 10 to 35 per 
cent, of Italian insanity is due to pellagra. 

In rarer acute cases, it may resemble typhoid in symptoms and 
pathology (status typhosus and swelling with ulceration of the intestinal 
lymph structures), or meningitis (foci of acute meningomyelitis). Other 
findings at autopsy are atrophy of the digestive mucosa, parenchy- 
matous degeneration and pigmentation, the latter of which is thought 
to occur from adrenal inflammation. Treatment is prophylactic 
(proper storage of the grain); change of diet or of locality is indicated, 
and arsenic should be given internally. 

3. Lathyrism (lupinosis) is produced by meal made from vetches, 
chiefly the lathyris sativus and cicera. Irving described the disease in 
India, and it has been also seen in Algiers and Italy. Like pellagra, it 
probably produces a lateral and possibly some posterior sclerosis of 
the cord, though no autopsies are reported. Clinically there is a 
spastic paraplegia with increase of reflexes and some paresthesia, 
but without atrophy. 

V. Potato Poisoning. — Solanin is contained in potatoes in small 
amounts (0.06 per cent.) but larger amounts (0.4 per cent.) occur in 
potatoes which lie for some time on the ground, or sprout in cellars. 
Fever, chills, general and cardiac weakness, alimentary irritation and 
jaundice may develop. 

(F). SUNSTROKE. 

Two forms are recognized, (1) sunstroke, and (2) heat exhaustion; 
the difference between them was first recognized by Dowler of New 
Orleans. 

Sunstroke, also known as siriasis, insolation, coup de soliel and 
thermic fever, is due to exposure to the sun. A very frequent factor 
is alcoholism. There is thought to be a paralysis of the bulbar heat 
centres, leading to excessive production of heat and deficient elimina- 
tion of it. The theory of infection has also been advanced. 

Symptoms may develop very abruptly, and cause early, or even 
immediate death from asphyxia and paralysis of the heart; this type 
was long confused with apoplexy. „ In most cases there is an interval 
lasting from a few minutes to an hour, in which there are headache, 
vertigo, visual disturbances or nausea, and perhaps vomiting. 

During the coma which develops rapidly, and in which the physician 
usually sees the patient, the following signs are observed: the face is 
first flushed, later rather cyanotic, and sometimes stained with petechia?. 
The preliminary pupillary dilatation passes into myosis, and the skin 
has a peculiar odor. The pulse is rapid, usually over 100, and is 
bounding. The rectal temperature ranges from 107 to 112° and 
respiration is deep, labored and stertorous. Save for the laboring- 
chest, the patient is usually quiet; in about 25 per cent, of the author's 
cases, they struggled during treatment by the cold bath, and in about 
20 per cent, of the severe cases there were epileptiform convulsions. 



SUNSTROKE 1255 

Lewis and Packard (1901) in 92 cases found convulsions and uncon- 
sciousness in all severe cases; immobile pupils and absent knee jerks 
were common. Involuntary evacuations are usual, and the thin 
fjeces have a peculiar odor. There is a leukocytosis in about 75 per 
cent, of the cases. Recovery is quite frequent; consciousness returns 
and the fever falls. Despite treatment, the Cheyne-Stokes breathing 
may develop, the pulse may grow smaller and more rapid, and death 
may follow, usually in a little more than a day. The autopsy shows 
early rigor mortis, fluidity of the blood, great venous hyperemia, 
particularly in the brain and lungs, and dilatation of the right and 
contraction of the left ventricle. 

After sunstroke, the patient becomes extremely susceptible to hot 
weather. Epilepsy, multiple neuritis and mental symptoms are among 
its after-effects. The author saw one case with a temperature of 109° 
in which the fever fell with hydrotherapy but rose to 104°; in a few 
days, the complication was recognized to be typhoid. 

The diagnosis is easily made. Practically, there is but one possible 
cause of confusion, which is pontine hemorrhage, but the latter never 
develops nearly as high a temperature, and death is almost instantan- 
eous; should the patient survive for some time, the paralysis, which 
is usually of the crossed type, is obvious. 

Heat exhaustion may result from exposure to the sun or to high 
temperature with humidity; the cases which the author has seen came 
largely from laundries, basement stores, or engine rooms; heat exhaus- 
tion occurs also among stokers on steamers. The symptoms are those 
of a centric vasomotor paralysis. The skin is cool and livid, rather 
than red, and the rectal temperature is often 3 or 4° subnormal; the 
pulse is rapid and weak and the breathing is rapid but not labored. 
In short, the symptoms of collapse are present. Restlessness, anxiety 
and sometimes delirium are noted, though the sensorium is practically 
normal in most cases. 

Treatment. — In sunstroke the chief indication is reduction of the 
retained heat. It should be relieved by immersing the patient in a 
bath which is gradually cooled by large pieces of ice. Shock is averted 
by this means; cerebral congestion is lessened by placing a block of 
ice under the neck, an ice-bag on the vertex, and an ice-bladder over 
the anterior neck; active friction of the body and limbs with the open 
hands brings to the surface the blood, which is cooled by the bath and 
the rubbing with pieces of ice. With this treatment, few more than 
one-third of the cases should die. The patient should be taken from 
the bath when his rectal temperature is 102°, for the fall usually continues 
after cessation of treatment. Laxatives are generally unnecessary, 
for the bowels move freely. Heart stimulants should be given pro 
re nata. For convulsions, a little chloroform by inhalation, and a 
hypodermic of morphine are indicated. Asphyxia and distention of 
the right heart are relieved by phlebotomy. 

In heat prostration, the treatment is diametrically the opposite: 
a warm bath or hot bricks for subnormal registration, diffusive car- 



1256 INTOXICATIONS. SUNSTROKE 

diants as ammonia, camphor and strychnine, saline solutions under the 
skin, and applications of mustard are indicated; cold and venesection 
are obviously contra-indicated. 



SECTION XI 



DISEASES DUE TO ANIMAL PARASITES. 



(A). DISEASES CAUSED BY CESTODES. 

Tapeworms were known to the Egyptians, to the Hindus and proba- 
bly to the Jews. They may cause symptoms by the presence of the 
mature parasite in the bowels or of the larval form in the viscera. 



Taenia Solium. 

I. The Taenia solium or pork tapeworm exists as the cysticercus 
cellulosae in hogs, and rarely in dogs, rats, or deer, as " measles" 
(measle or bladder worms). Cysticerci (the larva?) are found in the 
intermuscular tissue, particularly of the under surface of the tongue, 
in the masseters, shoulders, neck and diaphragm. They are easily 
seen with the naked eye and very easily with a low-power lens, as 
small opaque white bodies. They are much more frequent in Asiatic 
and German than in American pork. Man is infected by eating raw 
or partly cooked pork; the cysticerci develop in the upper ileum into 
the taenia ("band or ribbon-like") solium (referring to its usual soli- 
tary appearance, though 2 to 3, and even 20 to 41, have been found). 
Its head (scolex) is round, often gray or black in its upper part, is 
smaller than a pin head, and is attached to the upper ileum; it has 
4 sucking disks and 20 to 30 hooklets, arranged in an anterior more 
numerous row, and a posterior row, whence the name "armed" tape- 
worm; it has no real mouth. See figs. 81, 82, 83, 84. Its neck is thin 
and not jointed, to which the segments ("proglottides") are attached. 
These number 800 or more; the segments measure 1 cm. in length by 7 

1257 



1258 



DISEASES DUE TO AXIMAL PARASITES 



Fig. 81. 





Ova of T. solium: a, with yolk; b, with- 
out yolk, as in mature segments. The 
hard brown shell is indicated. (Leue- 
kart.) 



Fig. 82. 



mm. in width; those near the neck are narrower and shorter. About a 
yard from the neck they become squarer, and lower down they are 
smaller again. Each proglottis is hermaphroditic, containing male and 
female reproductive elements. The uterus is central and vertical, with 8 
to 10 lateral branches; only a few of them mature, chiefly those in the 

lower links; the ova (0.036 x 0.03 
mm.) are very numerous in each ma- 
turing segment and each one shows a 
shell and an embryo armed with six 
booklets. The taenia reaches its full 
length of two to four yards in three 
to four months, when the lower seg- 
ments are detached and voided; if 
the worm should break and a yard or 
so appear in the faeces, the segments 
will not reappear in the faeces until 
three or four months later. An ovum ingested by a hog or man, loses 
its shell in the stomach and the freed embryo passes into the tissues, 
where, encysted, it becomes again the cysticercus cellulosae (or larva). 
Symptoms of the Taenia Solium in the Human Intestine. — Many, 
possibly most, cases present no symptoms; they may first develop 
after passing segments are found in neurotic 
subjects. In other cases dyspeptic disturb- 
ances arise, as anorexia (or less often increased 
or ravenous appetite), nausea, abdominal 
pains, constipation or diarrhoea. Stiles, in an 
experimental infection on himself, thought 
that he could feel the parasite move. Vom- 
iting of segments is rare, though several feet 
of tapeworm have been vomited; in these 
instances the ova (embryos) may enter the 
tissues as cysticerci; this is a rare condition 
in which one individual suffers from both the 
intestinal and the larval stages. Anaemia is 
rather uncommon. In children reflex convul- 
sions are possible. The parasite may live for 
even 10 to 15 years. The diagnosis is deter- 
mined by the segments and ova, and the 
prognosis is practically always good. 

Treatment. — As to prophylaxis ; segments 
of the tapeworm should be burned; meat in- 
spection should be more general than it is, though "interstate" meat 
is well inspected; pork should always be thoroughly cooked. 

To cure the disease, a light and chiefly fluid diet should be given 
for two days, and then food should be withheld for 12 to 18 hours; 
this often causes the parasite to release its hold on the mucous mem- 
brane; some writers advise that a meal of onions and herring be given 
just before drugs are administered. Of these pomegranate ranks 




Head of T. solium: X45. 



TJSNIA SOLIUM 



1259 



Fig. 83. 



first; a decoction is made of 3 ounces of the root with 8 ounces of 
water; this is reduced to 4 ounces by evaporation; it is taken in divided 
doses within 3 to 4 hours ; its sole active principle is the expensive 
pelletierine, which is given in doses of 3,5 or 10 grains, and is followed 

by a purge in an hour. Male fern (felix 
mas) is almost equally effective; it is given 
as the oleoresina aspidii, or extr. felicis 
maris aether., 3i ss to ijss, may be given in 
syrup; both are followed by a saline purge 
in three to four hours. Castor oil is never 
gj pgfy iSfe used, because it promotes absorption of the 

male fern, which causes toxic symptoms as 
icterus, or amaurosis; Sidler collected 78 
such cases of poisoning with 15 per cent, 
mortality and lasting blindness in 25 per 
cent.; Leichtenstern advises (a) that more 
than 10 gm. (5ii ss ) of the ethereal extract 
should never be given to adults (5i or less 
to children); (b) that it never be given on 
an empty stomach and (c) that it never be 
given two days in succession. The drug 
decomposes easily, whence reliable prepara- 
tions must be obtained. Combinations may 
be made by giving with or after the decoc- 
tion of pomegranate, spts. chloroformi (ttj? xv) for four doses, or croton oil 
(ttjj ii) for one dose, but pomegranate and male fern produce the best 
results. Search should be made for the head of the parasite, without 
removal of which treatment is unsuccessful. If it is not found, 
another trial should be made after a number of days. 




Proglottides of (a) Tcenia saginata 
and (b) T. solium: natural size, 
and enlarged three times to show 
arrangement of uterus. (After 
Leuckart.) 



Oleoresinse aspidii 
Tr. vanillae . . 

Acaciae 

Sacchari albi . . 

Aquae 

M. et ft. emulsio. 
S. — Take in one dose. 



aa gtt. xlv. 



01. 

oi- 



Fig. 84. 



Symptoms of the cysticercus celluloses. These result when ova of 
the taenia solium are taken into the stomach; ova may reach the 
stomach from the intestines by 
antiperistaltic movements during 
vomiting, or indirectly by handling 
worms voided from the bowels. 
Cysticerci in the hog produce few 
symptoms. In man, symptoms de- 
pend largely on the number and 

localization of the larvae. (a) In Eggs of (a) T. saginata; (b) T. solium; 
the muscles and skin, a few CVSti- BotoHocephalus lotus: X300. (After EiA- 




1260 



DISEASES DUE TO ANIMAL PARASITES 



cerci cause no symptoms; numerous cysticerci cause pain, tenderness 
and difficult movement. Diagnosis is possible only on excision of 
the subcutaneous nodules. In Stiles' collection of 155 cases, the 
localization was muscular in 20 per cent, and cutaneous in 3 per 
cent, (b) If they are in the brain (in 75 per cent, of Stiles' series) 
symptoms depend on their location; they are often absent; if the 
location is in the cortex, Jacksonian epilepsy is frequent, and if in 
the medulla, diabetes may develop, (c) There may be other localiz- 
ations. They may be found clinically in the eye (v. Graefe), and 
a few other localizations are found at autopsy, as pulmonary, renal, 
or hepatic. There is no treatment except surgery. 



II. Taenia Saginata (Mediocanellata). 

This form is most frequent in America, 
but is becoming more common in Europe. 
It is the " fat tapeworm/' the " unarmed," 
or beef tapeworm. Its cysticercus is found 
in masseters of beef, nearly seven times as 
frequently as in other muscles, or in the 
heart, or brain. They 
FlG - 85 - are not so readily 

seen with the naked 
eye as the cysticerci 
in pork. Ingestion 
of rare beef contain- 
ing cysticerci pro- 
duces the taenia sag- 
inata in man. 

The intestinal par- 
asite differs from the 
T. solium in the 
following points : (a) 
its head is larger, 
measuring 2 mm. and 
is square. It has no 
hooklets but four 
sucking disks, which 
are larger, more forward and are surround- 
ed by pigment. (See figs. 83, 84, 85 and 
86.) (b) Its neck is much shorter, (c) Its 
proglottides are longer (16 to 22 mm.) and 
broader (5 to 10 mm.), (d) The uterus con- 
tains 20 to 30 branches, which are less 
dendritic than pronged or forked, (e) The 
ova are rather longer. (/) The parasite 
is larger and longer, measuring 5 to 7 me- 
ters or yards. Its symptoms and treatment 



Fig. 




Head of Taenia saginata. 
(Eichhorst.) 









Taenia saginata: natural s ; ze. (Af- 
ter Leuckart.) 



OTHER T.EXLE OCCURRING IX MAX 



1261 



are those of the taenia solium. Ingestion of the ova or segments 
produces the cysticercus mediocanellata, which is common in beef 
but extremely rare in man. 



III. Other Taeniae Occurring In Man. 



The Bothriocephalus lotus, 
or the Russian tapeworm is 
found chieflv in Russia, Po- 
land, Norway, Sweden, Switz- 
erland and Japan. Its cysti- 
cerci are found in the muscles 
and peritoneum of the pike, 
trout, salmon, and perch and 
in man's intestines develop 
into the bothriocephalus. Its 
head is flat or ovoid, possesses 
no hooklets and attaches it- 
self to the intestines by two 
lateral grooves (suckers). Its 
neck is long and its segments 
broad, square, and may even 
number 4,000. It is long, 
measuring 8 to 10 yards. It 
occurs in America in imported 
cases. It may produce a pro- 
found anaemia which in severe 
cases closely resembles the 
pernicious type in its general 
symptoms and blood findings. 
(See figs. 84, 87.) 

The Taenia elliptica or cu- 
cumerina (Dipylidium cani- 
num) is a form, the larvae of 
which develop in the lice of 
dogs, and the adult form exists 
in the intestines of dogs, some- 
times in those of cats, and 
rarely in man. (See fig. 88.) 

The Tcenia na- 
na (Hymenolep- 
sis nana) is the 
dwarf tape- 
worm. It mea- 
sures but I to 2 
in, ches in length. 
Its cysticercus 



Fig. 87. 



Fig. 89. 



Proglottis of Both- 
riocephalus latus: 
natural size, and 
enlarged three 
times. (After 
Eichhorst.) 



Fig. 88. 




Taenia cucumerina: 
natural size. (Af- 
ter Leukart.) 



Fig. 90. 




«v/ 



Ova of Hymenolepsis nana. (Smith.) 



WWOS M B T 



Hymenolepsis nana: \\2 
(After Leuckart.) 



1262 DISEASES DUE TO AXIMAL PARASITES 

stage is in the intestinal wall of the rat and its adult stage in the 
rat's intestine. Stiles has recently decided that it is much more fre- 
quent in man than previous accounts would indicate. Its head 
contains four suckers and one row of hooklets. It may occur singly 
or in myriads. Aspidium alone is of therapeutic benefit. (See Figs. 
89 and 90.) 

Taenia Echinococcus. — Echinococcus Disease. 

We may first consider the adult parasite as inhabiting the intestine 
of the dog chiefly, and rarely of the wolf, fox or jackal. The head is 
small, and is provided with four suckers, and from 30 to 50 hooklets 
arranged in a double row. The segments number only three or four, 
and only the end one matures; it measures but 0.6 by 2 mm. but con- 
tains even 5,000 ova. The worm is small, measuring but four to five 
mm. in length, is very delicate and white, so that it readily escapes detec- 
tion. When the ovum reaches the stomach of another animal, the hog 
and ox chiefly, and less often the horse, sheep or man, it loses its shell 
and migrates to the various organs (v. Symptoms). The geogra- 
phy of echinococcus disease and mode of infection is as follows : In 
Iceland, where dogs and men live together, the disease in man is common, 
every seventh person becoming infected. In Australia both men and 
sheep are often infected. In Europe the malady is much more common 
than in America, where the reported cases in 1901 numbered 241 
(Lyon); most of these were foreigners. The Icelanders brought the 
disease to Manitoba in 1874. 

Infection occurs by licking of the hands by the dog, the tongue and 
anus of which often come in contact. Infection by contaminated 
drinking water or vegetables is less common. 

General Symptoms and Pathology. — The small embryo, freed of 
its shell, penetrates the intestinal wall and wanders in various directions, 
into the muscles or peritoneum or into the radicles of the portal vein 
or cava, so that almost any tissue or organ may be infected, and the 
embryo merely stops when it reaches vessels too small for it. Once 
lodged, its hooklets disappear and a cyst develops, which is small at 
first but gradually reaches large or enormous proportions; there are 
records of cysts containing 30 and 70 pints of fluid. Its layers consist 
of an inner endocyst which is granular, and an outer finely lamellated 
structureless capsule ; a fibrous layer develops outside from reaction of 
the tissues to the foreign body. After a while a number of " daughter " 
cysts arise from the endocyst; these are first "buds" and then minia- 
tures of the original mother cyst; from these daughter cysts, which 
number about a dozen, "granddaughter" cysts arise by an identical 
process. Allen in one case found 8,000 daughter cysts. Finally from 
the endocyst of the maternal and daughter cysts there develop "brood 
capsules, " in which small buds arise, which gradually become scolices 
(the heads of which will be intestinal taenia? in the animal which ingests 
them). Some cysts do not develop scolices and are therefore called 



TMNIA ECHIXOCOCCUS— ECHINOCOCCUS DISEASE 



1263 



sterile. In animals the daughter cysts may grow outward (exogenous 
cysts) . The well-grown cyst contains fluid (v. Liver and Lung Echino- 
coccus); it is clear and neutral, has a specific gravity of 1005-10-15 
and contains succinic acid, inosite (possibly sugar) and much sodium 




Human echinococci. (From Finlayson, after Davaine.) 

A, a group of echinococci, still adhering to the germinal membrane by their pedicles. X40. 

B, an echinococus with head invaginated in the body. X 107. 

C, the same compressed, showing the suckers and hooks of the retracted head. 

D, echinococcus with head protruded. 

E, Crown of hooks, showing the two circles. X350. 

chloride but no albumin, unless the parasite dies and cystic inflamma- 
tion develops. Then the fluid may become cloudy, buttery, gelatinous, 
purulent, brownish or grumous; the cysts disappear as w T ell as the 
membrane, though the hooklets of the scolices remain a long time. 
When the parasites are alive a toxin seems to be present, for collapse 



Fig. 92. 



^ 






* 






$J? 



^ 



Hooks from Taenia echinococcus. X350. (Corti.) 



often develops when the cyst ruptures or is punctured (see Lung 
Echinococcus). 

The parasite is said to live for years, in one instance it survived for 
20 years; after a variable time, unless suppuration intervenes, the 
cysts become cheesy and perhaps calcified or ossified. 



1264 DISEASES DUE TO ANIMAL PARASITES 

The parasite may rupture into the serous sacs, bloodvessels (causing 
embolism), into the air passages, urinary tracts or externally (see 

ECHINOCOCCUS OF THE LUNG, LlVER AND KlDNEY). 

Visceral Localization. — In 1,912 cases (the total reported by Davaine, 
Finsen, Mosler, Neisser and Cobbold) the liver was involved in 51 
per cent., the genito-urinary organs in 10 per cent., the intestinal canal 
in 9 per cent., the lungs or pleura in 9 per cent., the brain or cord in 7 
per cent., the bones in 3 per cent., the heart and vessels in 3 per cent., 
and other organs in 8 per cent. Vegas and Cranwell (1902) reported 
970 Argentine cases of which 64 per cent, occurred in the liver and 7 
per cent, in the lungs. In statistics from single observers, percentage 
of cases with localization in the liver often runs higher (69 to 72 per cent). 
Thomas, in 809 Australian cases of single hydatid cyst, found the lungs 
involved in 16.5 per cent. Hooklets have been obtained by lumbar 
puncture (Jacobs). There are reported 142 cases of renal echinococcus, 
78 cases with localization in the bones and 23 in the pelvic bones 
(Baradulin, 1906). Grulee in 1905 found 55 cases with cardiac or 
pericardial localization. Echinococcus cyst of the thyroid has been 
reported 23 times (Ehrhart, 1905). 

There is an unusual form of echinococcus, the multilocular form, 
probably due to a separate worm, the clinical features of which are 
described under hydatid disease of the liver to which it is almost 
exclusively confined. Virchow first described it in 1856. It occurs 
in Bavaria, Wurtemburg, Switzerland, Austria, Austrian Tyrol and 
Russia. Few imported cases have occurred in America. It is un- 
known where the ordinary form is most common. It is rare, few more 
rhan 100 cases being recorded. Sixty per cent, occurs in males between 
20 and 50 years of age. The ova are spheroidal and measure 100 to 
170 micro-millimeters. The great difference from the ordinary form 
is the outward (exognous) growth of the cysts. The irregular and 
diffuse cystic proliferation is an unfavorable feature. The cysts 
contain a gelatinous material (which sometimes causes confusion with 
colloid cancer), surrounded by intersecting fibrous strands, which gives 
the liver a porous appearance, like a sponge or cheese with air cavities. 
In some vesicles there is cheesy material, with some resemblance to 
the granulomata. The vesicles sometimes suppurate. 

Echinococcus cysts which cause symptoms belong largely to sur- 
gery, though as described elsewhere, spontaneous recovery is not 
infrequent. 

(B). DISEASES CAUSED BY NEMATODES. 
I. The Ascaris Lumbricoides. 

This is the most common intestinal parasite in man. It occurs 
oftenest in children and with relative frequency in the insane. Unlike 
the cestodes, no intermediate host is required. The female measures 7 
to 12 and the male 4 to 8 inches in length; it is smooth, pointed at both 



THE ASCARIS LUMBRICOIDES 



1265 



Fig. 93. 



ends and has transverse rings and four longitudinal ridges, a white one 
dorsally and ventrally, and two brownish ones laterally. (See fig. 93.) 
The ova measure 0.075 x 0. 058 mm., are oval and reddish and have a 
thick capsule. It is said that 60,000,000 
eggs may develop in a single female. It 
lives in the upper small intestine; its mode 
of infection is obscure. Though they usu- 
ally occur singly or in pairs, they may 
exceptionally develop in such numbers that 
by intertwining, they may obstruct the in- 
testine. The ascaris may rarely rupture 
through an intestinal ulcer or perforate the 
sound gut. It has passed through a per- 
forated appendix. With or without vomit- 
ing, ascarides may pass from the stomach 
into the oesophagus, nose, bronchi, lungs 
or middle ear, causing asphyxia, gangrene 
of the lung, etc. They may migrate into 
the common or hepatic duct. 

Symptoms are not usually pronounced, 
though anorexia, salivation, offensive breath, 
constipation, colic or diarrhoea occur in some 
cases. Malnutrition is sometimes marked. 
The parasite secretes an irritating substance 
which is often noted to emanate from it. It 
is suggested that this secretion, if absorbed, 
may cause constitutional symptoms (Peiper). 

Such manifestations as irritability, grind- 
ing the teeth, muscular twitchings and con- 
vulsions may develop in nervous children; 
they are said even to resemble meningitis. 
The author always doubted the existence 
of the typholumbricosis of Chaffard, Marie 
and Tauchon, until in one adult case, in 
which there were fever and nervous toxaemia, 
with otherwise negative findings, instan- 
taneous subsidence of all symptoms oc- 
curred when the parasites were removed; 
this strongly suggested a relation between 
the fever and other symptoms and the 
lumbricosis. 

Treatment.— After a fast of one-half to 
one day, santonin should be given in doses 
of gr. ss-i, for a child, and gr. ii, iii, or v, 
for an adult; it should be followed by a 
saline cathartic; if unsuccessful it may be 
repeated on two or three successive days, though toxic symptoms 
sometimes develop, as xanthopsia (yellow vision), urticaria (which 

80 




Ascaris lumbrieoides ,'dissected and 
walls thrown back: a. genital 
orifice; b, intestine, c, oviducts; 
d, longitudinal band; e, ovaries. 
(Heller.) 



1266 



DISEASES DUE TO ANIMAL PARASITES 



may result from the parasite itself), vomiting, delirium or convulsions. 
The extr. spigelice fl. (5i) may be given with or without the santonin. 
These remedies do not kill the parasite, but merely render it uncom- 
fortable. 



II. Oxyuris Vermicularis (Seat Worm, Pin or Thread Worm). 



Fig. 94. 



Fig. 95. 





Children are more often affected than adults, and women more often 
than men. They are relatively frequent in the insane. The female in 
length measures 10 and the male 4 mm. (See Figs. 94, 95 and 96.) 

Ingested ova develop in the small intestine, 
where the worms mature and cohabit; 
afterward they exist chiefly in the lower 
colon and rectum. The eggs remain in the 
mother until the worm is expelled, though 
she occasionally "aborts" in the bowel. 
Infection occurs in those who are the most 
uncleanly, as in children and the insane. 
Infection may occur from water and green 
vegetables, and reinfection is not uncommon 
from scratching the 
anus -during sleep 
and thus crushing 
the parasite; Eich- 
horst frequently 
found ova in the 
minute fsecal parti- 
cles about the anus 
and Zenker demon- 
strated repeatedly 
their presence 
under the finger 
nails. As the par- 
asites migrate at 
night, the symp- 
toms are greatest 
at that time; they 
may be found on 
the bed sheet. The 
anal itching and 
rectal irritation are 
often excessive; 
periproctal suppuration may be excited. If any vaginal discharge 
moistens the perineum (and only then), they can wander into the 
vagina, causing irritation, sexual stimulation or masturbation. Dis- 
turbance of the sleep and appetite, nervous symptoms and anaemia 
may result. Diarrhoea is due to large numbers of parasites. 



Eggs of Oxyuris vermicularis: 
X 275 . (After Eichorst .) 

Fig. 96. 




Oxyuris vermicularis, magnified: a, 
young female; 6, male; c, mature 
female, full of eggs. (Payne.) 



Oxyuris vermicularis: natural 
size. (Eichorst.) 



TRICHINA (TRICHINELLA) SPIRALIS; TRICHINOSIS 1267 

Treatment. — Santonin may be given in obstinate cases, but local 
measures are usually sufficient, as high enemata containing small 
proportions of carbolic acid, quassia, and turpentine. They should 
be repeated daily for two weeks. Itching is palliated by application 
of h per cent, carbolic salve to or within the anus. 



III. Trichina (Trichinella) Spiralis; Trichinosis. 

Though Tiedemann (1822), Hilton (1832) and Paget (1835) saw 
the parasite, Owen (1835) first fully described it. Leidy saw it in the 
hog in 1847. Zenker (1855-60) first described its pathological and 
clinical bearings; he found 4 cases in 136 autopsies. 

Swine are infected in a manner which is not wholly clear, but in- 
fection most probably results from eating offal. The disease is rare 
in some countries, as France, and more common in others, as Germany. 
The hog is more frequently diseased in America than in Germany (a 
ratio of 1 to 17 [or 48] in the former and but 1 to 18,000 in the latter). 
From the clinical and etiological standpoint, the (a) muscular or 
larval stage in hogs should be considered first. The small encapsulated, 
"hair-like" (trichina) worm lies in the abdominal, diaphragmatic, 
psoas, laryngeal and other muscles. They live for a long while, even 
twenty to twenty-five years, without apparently causing any symptoms; 
calcification rarely occurs in swine. Man is injected by eating smoked, 
"cured" or insufficiently cooked pork; animals may be accidentally 
or experimentally inoculated, especially the rat, guinea-pig, rabbit, 
less often the cat, and rarely the dog. In much of the literature relating 
to its alleged presence in fish or worms, the trichina has been confused 
with other parasites, (b) The adult or intestinal stage in man is the 
next phase. When it is eaten by man, the small capsules (larval form in 
swine) are digested and the worms liberated; in the small intestine 
they mature (the females measure 3 to 4 mm., and the males are half as 
long) and the females are fecundated in two to three days. The female 
trichinae produce one to two thousand embryos at once or possibly in 
succession, which stage requires another week (from fecundation of 
the female to birth of the embryos). At the end of the second week the 
embryos commence to migrate; they enter the lymph vessels and 
then the veins, by which they reach the voluntary muscles; some 
writers, as Graham, maintain that there is a primary direct entrance 
into the venous system. They lodge between the muscle fibers, enter 
them and attain (c) the mature larval form, which is identical with the 
larval stage (a) in hogs, and differing only in that man is their host. 
They measure 0.5 to 1 mm. in length. As a result of tissue reaction 
against the foreign bodies, a capsule develops in about six weeks, which 
surrounds one or more parasites. The capsules are at first trans- 
parent, but grow more opaque and, after months, calcify and later the 
trichinae calcify also. 



1268 DISEASES DUE TO ANIMAL PARASITES 

Frequency. — Though trichinae are apparently about 40 times as 
frequent in American as in German swine, the disease is more common 
in North Germany where raw sausage, Westphalian ham and smoked 
ham are freely eaten. Frankel denies that German trichinosis results 
from American pork. Williams of Buffalo, in 505 autopsies, found 
trichinosis in 5 per cent. Miiller of Dresden found it in 0.98 per 
cent, of 1,939 postmortem examinations. Other statistics usually 
show lower figures than Miiller's, and like the above, are taken from 
accidental postmortem findings. The disease occurs sporadically 
or epidemically. Perhaps a thousand cases have occurred in America. 
In Germany the epidemic at Hedersleben numbered 337, and that at 
Emersleben 250 cases. 

Symptoms may be absent or slight, particularly in sporadic cases, 
and with moderately severe infection, as evidenced by accidental 
autopsy finding of encapsulated parasites. 

In clear cases the symptoms are divisible into two stages; (a) the 
preliminary or g astro-intestinal stage, which begins in two to three 
days after eating the diseased meat; the symptoms are not constant 
either in sporadic or severe epidemic cases; they are anorexia, nausea, 
vomiting, colic and sometimes diarrhoea, which may resemble the 
evacuations of cholera, (b) The invasion symptoms begin in one or 
two weeks, and correspond to the parasitic migration, (i) Fever is 
usual, but its onset seldom begins with rigors. It results from the 
parasites and probably from some toxin which they elaborate; it may 
rise to 102, 104 or 106°, and its course is remittent and intermittent. 
Symptoms which are attendant on any fever may be present, as head- 
ache, febrile urine, or quickened pulse. In severe cases, as in Zenker's, 
typhoid may be suggested by delirium, epistaxis, dry tongue, status 
typhosus, Ehrlich's diazo reaction of the urine (in 80 per cent.), 
bronchitis, albuminuria and kindred toxaemic symptoms. In two 
cases typhoid and trichinosis co-existed (McCrae). (ii) Acute diffuse 
myositis is always most suggestive. Its intensity varies from mild 
forms of "muscular rheumatism" to the most severe and characteristic 
involvement; there is pain, tenderness, swelling, flexion to relieve 
muscular tension, and oedema in the face and other locations. The 
worms most curiously select only the striated muscles, so that the 
oedema which is observed in the abdomen and thighs, for example, 
never invades the scrotum or vulva. The eyelids are often affected 
greatly and early. Invasion of the eye muscles causes pain on moving 
the eyes; pain during mastication, phonation and deglutition mark 
penetration of the masseteric, laryngeal and pharyngeal muscles by the 
parasite; dyspnoea results from involvement of the diaphragm and 
intercostal muscles. The tendon reflexes may disappear, (c) The 
blood presents two striking features: first, the leukocytosis (15,000 to 
30,000) and second, the eosinophilia (T. R. Brown); the eosinophiles 
normally constitute 0.3 to 4 per cent, of the leukocytes; their number 
rises as high as 50 or 68 per cent, and though they increase in the other 
parasitic diseases, this rise is most peculiar if not absolutely patho- 



ANKYLOSTOMA (UNCINARIA) 1269 

gnoraonic. The eosinophilia is greatest at the time when the trichinse 
enter the muscles. (See Plate XIV, Fig. 5.) (d) Profuse sweats, poly- 
uria, paresthesia, urticaria and anaemia are inconstant manifestations. 

Diagnosis. — This is based on (a) the possibility of infection, as by 
eating poorly cooked pork, (6) the discovery of trichinse in the uneaten 
portions of suspected meat, (c) the detection by removal of small 
slivers of the biceps or pectorals for microscopic examination, especially 
the parts near the muscular insertion, (d) the myositis with oedema or 
muscular rheumatism, (e) signs of particular muscular insufficiency, 
as of the ocular or diaphragmatic muscles and (/) leukocytosis with 
eosinophilia. 

Prognosis. — This depends on the number of parasites ingested. 
Choleraic and typhoidal symptoms, dyspnoea and pneumonia are most 
ominous. In moderately severe early diarrhoea it is favorable. 
Children die less often than adults. Convalescence is prompt or tardy 
as the infection is light or severe. According to Stiles, the German 
mortality averages 5.6 per cent. In the epidemic at Weimar there 
were no fatalities in 108 cases. In the epidemic at Hedersleben 30 
per cent. died. Instances have occurred when as many as 70 per cent, 
of those who were attacked have died. 

Treatment. — (a) Prevention comprises the feeding of hogs with 
clean food, government inspection of meat, and thorough cooking. 
(6) In the preliminary stage, active and repeated purgation should be 
given, for moderate and early spontaneous diarrhoea is prognostically 
favorable; calomel should be followed by salts and castor oil; male 
fern, santonin (v. s.), thymol gr. v, t. i. d., benzene tt£ ii to v, t. i. d. 
and oil of turpentine wn v to x are recommended; glycerine is now 
regarded as useless, (c) In the stage of muscular invasion, the fever 
is treated as in other infections, the myositis by local applications of 
ice and by narcotics, and the general nutrition by food and stimulants. 

IV. Ankylostoma (Uncinaria). 

The uncinaria duodenalis (ankylostoma duodenale) exists in two 
forms, that of the old and that of the new world. Ankylostomiasis 
was first well described by Piso (1648) in Brazil, and the parasite was 
recognized in Milan by Dubini (1838). It occurs chiefly in the tropics 
and sub-tropics; according to Thornton, it is the most dangerous of all 
tropical diseases. In Egyptian chlorosis it was found by Griesinger, 
and is said to be present in nearly every autopsy made there. It is 
epidemic in Italy ("brick-layers' 5 ' anaemia). In India it is found in 
even 80 per cent, of the healthy coolies and in 300 autopsies in Assam 
it was present 299 times. Thirty per cent, of Porto Rican deaths 
result from uncinariasis, and Ashford and King state that 90 per cent, 
of the rural and 50 per cent, of the urban population have the disease; 
during six months in 1905, 18,865 cases were treated in Porto Rico 
of which 33 per cent. died. It prevails in our southern states. Capps 



1270 



DISEASES DUE TO AXIMAL PARASITES 



Fig. 97. 






in 1903 reported one case, and collected 50 other American cases. 
More than twenty years ago, Belneld recognized the parasite in cats. 
In the Westphalian mines, Tenholt himself treated over 4,000 cases. 
It was the cause of the '.'tunnel anaemia," which was observed in 
building the St. Gothard tunnel. It is disseminated by Italian and 
Polish workmen. Infection occurs from ingestion of the larvae and 
not of the ova. Infection comes from the food, drinking water and 
earth which are infected by dejections from persons 
suffering with the disease. Loos has proven that it 
may enter by the skin, producing the "ground itch" 
which is common in the Southern States. The 
exact role of the uncinaria in clay eaters is not yet 
determined; the parasite certainly exists in some 
cases, though it is claimed that the dirt eaters in- 
stinctively eat clay to remove the parasite. The 
male is 8 to 10 and the female 10 to 18 mm. in 
length; the mouth has hooks by which it adheres 
to the mucosa of the duodenum. (See figs. 97, 98, 
and 99.) The ova measure 30 to 60 micromilli- 
meters; they are oval, are covered with a trans- 
lucent shell and differ from oxyuris ova which are 
flat. They show 1 to 6 yolk segments and may 
number over four millions. The larvae develop in 
moist earth, whence they infect the water or the 
fingers or enter through the skin. 

Symptoms. — Symptoms may be absent, or of a 
mildly dyspeptic character. In pronounced infec- 
tions (a) an ancemia develops which is first of the 
secondary type and later of the progressive pernic- 
ious type; anaemia results not only from sucking 
of blood by the parasites, but from haemolysis due 
to some toxin which they elaborate (in their sali- 
vary glands); normoblasts are much more common 
than megaloblasts, poikilocytosis is less marked 
than in the usual pernicious type, and the eosinoph- 
iles are increased, and sometimes reach 30 per cent, 
of the total number of leukocytes, (b) Gastro- 
intestinal symptoms are usual, as ink-like patches 
on the tongue, diarrhoea and colic; in Herrick's Panama case (re- 
ported by Capps) which the author saw in the County Hospital, 
there was great nausea, pain and exquisite abdominal tenderness; 
the stools contained blood, eosinophile cells, Charcot-Leyden crystals 
and ova. Stiles suggests a ready test for blood, by which parts of the 
stool are placed upon blotting paper; after an hour or so a rusty 
stain develops about the stool. Gastro-intestinal catarrh and small 
ecchymoses are found at autopsy, (c) Nutrition suffers; as in per- 
nicious anaemia, oedema develops. Clay eaters are emaciated and 
apathetic ; debility is frequent. In young children puberty is retarded ; 



b a 

Uncinaria duodenalis 
magnified: a, female; 
b, male. (Bristow.) 



AXKYLOSTOMA (UNCINARIA) 



1271 



development is poor and the abdomen is greatly distended. Cardiac 
atrophy and dilatation are common. The prognosis is grave, though 
less serious in the New World than in the Old World type. 



Fig. 








Above; to the left, three ova of Uncinaria Americana in different stages of segmentation, from 
66 p. to 68 ft in long diameter; to the right, three ova of Uncinaria Americana in varying stages of 
segmentation, long diameter from 58 f)- to 62 fl. 

Middle: to the left, the head of Uncinaria Americana (dorsal view), exhibiting the smaller size 
of the head and more tapering anterior extremity of the worm in comparison witn U. duodenalis, 
and its buccal armature consisting of lips; to the right, the head of Uncinaria duodenalis (dorsal 
view), drawn to same scale, showing its greater size and the hook armature of the buccal border. 

Below: to the left the caudal border of male Uncinaria Americana (dorsal view, dorsal lobe of 
bursa thrown forward), showing comparative size of the worm in relation to that of U. duodenalis 
partly divided dorsal lobe and suggestion of a ventral lobe, the dorsal ray divided nearly to base, 
each of its divisions having a bipartite tip, showing also the tip of tail within bursa, the long barbed 
sexual spicules, and the arrangement of the rays of the bursa; to the right, caudal bursa of male 
U. duodenalis, showing larger size of bursa, entire dorsal lobe, absence of ventral lobe, division of 
dorsal ray limited to distal third and tripartite tips of each division, with other features in genera 
similar to U. Americana. (Smith.) 



1272 



DISEASES DUE TO ANIMAL PARASITES 



Treatment. — 1. Prevention. — Drinking water should be boiled, 
and the hands should be cleansed before eating. The stools should 
be received in water-tight closets and disinfected; careless defecation 
in mines has caused wide dissemination of the disease. Mines should 
be disinfected with the milk of lime. 



Fig. 99. 




Uncinaria duodenalis, with eggs. (After Blickhan.) 

2. Medication. — Thymol is the most efficacious remedy. After a 
light diet, 5 ss should be given, and this should be followed by an 
equal dose in two hours, and by a saline purge two hours afterward. 
As toxic symptoms (nervous excitation, or smoky urine) may develop, 
no solvents of thymol should be given, as alcohol, chloroform, ether or 
castor oil. This treatment should be repeated once a week, as long as 
ova or Charcot-Leyden crystals appear in the stools. The most 
severe cases do not respond to any treatment. Male fern is considered 
the best remedy by Tenholt, and other Westphalian writers. 

V. Filaria. 



Demarquai (1863) first found the embryos of the filaria; Wiicherer 
(1866) found them in the urine, and Lewis (1872) in the blood. 

Filaria Nocturna. — Its distribution is largely tropical and sub- 
tropical. It occurs in 10 to 50 per cent, of the inhabitants of the Samoan 
Islands, and in 32 per cent, of those of the Friendly Islands. In the 
United States it has been found in the South, and also in New York, 
Illinois and Pennsylvania, (a) Infection of man occurs by mosquito 
bites or possibly by water which the mosquito contaminates with its 
eggs. In the mosquito, the embryos change to the young adult form. 

(b) The next stage is the presence of adult filaria in the lymph 
channels, where they cause lymph stasis and lymphangitis. The 
female filaria measures 155 x 0.7 mm. and the male 83 x 0.4 mm. 

(c) The embryos enter the blood current from their birth place, the 
lymph channels; they are very numerous, measure -J inch in length, 
and have the same diameter as a red blood cell. Under a low power 
lens their active movements are easily seen. They appear in the blood 
only at night, usually near midnight, and during the day retire to 
internal organs as the lungs but if the patient sleeps by day, they 
appear in the day time only. 

Symptoms are absent in the majority of cases of human and animal 
infection, and are due to the parent worm, not to the embryos, (a) 
Chyluria or hsematochyluria is due to plugging by the worm of the 



DRACUNCULUS (FILARIA) MEDINENSIS 1273 

lymphatic vessels in the peritoneum, pelvis, vesical and perirenal 
tissues. Lymph stasis, ectasia and lymphangitis result, with inter- 
mittent rupture into some part of the urinary tract, and the passage of 
milky chylous urine, containing molecular albumin and fat. The 
amount of the urine varies; it may be normal, or increased. There is 
usually also some blood. If the blood clots, vesical disturbance results. 
The embryos are often found in the blood and sometimes in the urine; 
there is also a non-filarial chyluria (page 806). The affection may last 
for years without impairment of health. The very rare rupture into the 
peritoneum causes chylous ascites, (b) The lymph scrotum is due to 
lymphatic obstruction by the adult worm. The scrotum may weigh 
50 to 200 pounds. Rupture into the tunica vaginalis causes chylocele. 
The labia may be similarly involved. The embryos are often missing 
from the blood, being apparently confined to the local involvement by 
the lymphangitic thickening, whence the difficulty in stating the 
relative percentage of parasitic and non-parasitic cases of lymph 
scrotum and elephantiasis, (c) Elephantiasis usually develops in the 
legs, scrotum (v. s.) and labia, less often in the arms, breasts or trunk. 
In forms (b) and (c), there occur intermittent exacerbations with fever 
and nervous disturbance, which end with critical sweats. 

Other Forms of Filaria. — The exact status of the filaria diurna is 
not known; /. per starts, which causes pustular eruptions (craw-craw); 
/. loa (the adult stage of filaria perstans) which inhabits the conjunc- 
tiva; /. labialis; and /. oris, and bronchialis, are other forms. 

Treatment. — (a) For prevention, mosquito bites and infected water 
should be avoided, (b) No parasiticide is known, (c) Chyluria is 
treated expectantly; a dry and fat-free diet is recommended but it is 
difficult to understand how it can influence lymph stasis, (d) Lymph 
scrotum and elephantiasis may necessitate castration, amputation or 
less radical measures to eradicate the obstructing parasite. 

VI. Dracunculus (Filaria) Medinensis. 

This is found on the West African coast, the Gold Coast, in Abyssinia 
and South Egypt; on the Caspian Sea and Persian Gulf; in the East 
Indies, parts of India, and South America. Guinea-worm disease 
(drachontiasis) has developed in a person who had always lived in 
Philadelphia. Man is infected by a small water flea (cyclops) which 
contaminates the water with the larvae (embryos). These embryos, 
measuring 0.6 mm., enter the stomach, bowel and probably the 
mesentery, where they copulate; the male, of which little is known, 
is either discharged from the bowel or dies in the mesentery. The 
female is cylindrical in form, measures 50 to 80 x 2 mm., has a tri- 
angular mouth, eight papillae and a blunt tail; its uterus occupies 
almost its entire length. The female which is usually solitary, wanders 
downward in the subcutaneous and intermuscular tissues to the 
thighs, legs and in 66 per cent, of cases readies the feet where, near 



1274 



DISEASES DUE TO ANIMAL PARASITES 



its head, vesicles, abscesses and ulcers develop. Its downward course 
occupies a year, during which it may be felt subcutaneously. When 
the skin breaks the parasite discharges her embryos and then leaves 
the body, to die. 

Treatment. — Treatment by excision, or by 1 to 1,000 bichloride 
injections, seems most rational. If the worm is ruptured in efforts to 
extract it, high temperature, alarming nervous symptoms and sepsis are 
said to result from migration of the embryos which are liberated in 
the tissues. 



VII. The Trichocephalus Dispar or Whip Worm. 

This is a nemotode, which is found most often in Southern Italy and 
France and but seldom in this country; one case occurred in the County 
Hospital service. It is also called trichuris trichura. It requires no 
intermediate host, enters with the food and drink, and is found in the 
caecum and large gut. The male is slightly shorter than the female 
which is 4 to 5 cm. in length. The anterior portion of the worm is 
thin; the posterior two-fifths is thick, in the male round and in the 
female pointed. It bores into the mucosa and is nourished by the 
blood and not by the alimentary contents. The eggs measure 0.05 
mm., are oval and are marked by a button-like projection. It causes 

Fig. 100. 

Fig. 101. 






Eggs of Trichuris trichura: X275. 
(After Eichorst.) 



Trichuris trichura, male and female: natural 
size. (Eichorst.) 



few symptoms; occasionally there is severe abdominal pain. Three 
fatal cases are recorded. Male fern and thymol internally and benzene 
3i to Oij of water as an enema are recommended. (See figs. 100 
and 101.) 



VIII. The Strongyloides Intestinalis. 



This includes a number of nematodes, as the anguillula intestinal 
or stercoralis, rhabdonema, etc. They are found in the endemic diar 
rhcea which occurs in Cochin China. Strong reports cases from 
Manila, and W. F. Thayer reported the first case in America. A few 
parasites cause no symptoms. Thymol is almost specific. 



DISEASES CAUSED BY TREMATODES (DISTOMIASIS) 1275 



(C). DISEASES CAUSED BY TREMATODES (DISTOMIASIS). 

1. Bilharzia disease (endemic hematuria) is due to the blood fluke 
(Cystosoma haematobium). Bilharz described the disease in 1851. It 
is an African affection; it has prevailed for many centuries in Egypt, 
where Bilharz considered that half of the lower classes were affected. 
It is equally frequent in Uganda. Importation has occurred into 
India, the Mediterranean Islands, and America. Only six cases have 
occurred in the United States (Gunn, 1906). 

Children are more predisposed than adults to infection, which 
occurs through the drinking water or possibly through the skin. The 
embryos enter the stomach, penetrate the alimentary mucosa, and 
mature in the veins of the pelvis, spleen, mesentery, liver, kidney and 
bladder. The male worm measures 4 to 15 x 0.6 mm., the female 
15 to 20 x . 3 mm. The male is rolled up like a leaf, forming a groove 
in which the female lies during copulation. Many ova are found in 
the urine; they are oval, carry a spine, and contain a ciliated embryo. 
They die in the urine in a day but live for some time in water, where 
their life history is still imperfectly understood. 

Hcematuria is the most common, and often the only symptom; it 
may be macro- or microscopic and passes chiefly at the end of urination; 
its examination shows many ova and eosinophiles. Cystitis occurs in 
severe infection. Stones are not uncommon, particularly in cases in 
Canton, China. Suppuration may develop fistula?. These clinical 
symptoms result from massive accumulation of ova in the submucosa, 
which leads to papillomatous hyperplasia, hemorrhage, suppuration, 
necrosis, salt deposits '(calculi), and rarely to malignant degeneration. 
Similar changes in the rectum cause pile-like papillomata, dysenteric 
evacuations and tenesmus. As complications, pyelitis, prostatitis and 
changes in the uterus, seminal vesicles and renal pelvis, resembling 
those in the bladder, may develop. The eosinophiles are increased to 
10 to 50 per cent. 

Treatment. — Change of climate is advisable in order to avoid 
infection. The parasites usually die, though slowly, and as no local 
application or systemic remedies modify their life history, treatment 
must be expectant. 

2. Lung flukes cause the endemic haemoptysis which is observed 
chiefly in North China, Corea, Japan and Formosa. The parasite is 
named Distoma pulmonale (Paragonius Westermanni) ; it measures 
10 x 6 mm. and is found largely in the lungs, but sometimes in the 
brain and skin. In young males a chronic cough develops with bloody 
or prune-juice sputum, in which are found blood, dark brown ova, 
eosinophile cells and Charcot-Leyden crystals. The hemorrhages, 
which are sometimes profuse, result from small infarcts of ova in the 
subpleural lung tissue. The course is usually favorable, though 
chronic, and is not influenced by treatment. 



1276 DISEASES CAUSED BY ANIMAL PARASITES 

3. Liver flukes (Fasciola hepatica, Opisthorchis siensis) enter like 
the above forms through contaminated water. The fluke is found in 
the upper small intestine, and the bilary or pancreatic duct. It is 
found in Japan, and certain provinces show a mortality of 20 to 72 
per cent. (Balz and Inouye). The liver is enlarged and tender; 
icterus results from biliary stasis, for the parasites lie in the walls of the 
biliary duct and gall-bladder; diarrhoea develops, and the dejections 
contain ova and blood; anaemia, ascites, anasarca, adynamia, and 
emaciation develop and death invariably results. There is no treat- 
ment beyond the symptomatic support of the heart. Prophylaxis is 
valuable; avoidance of drinking or of swimming in canal water, and 
thorough cooking of fish and mussels, has stamped out the plague in 
one Japanese province (Inouye). 



(D). DISEASES CAUSED BY PROTOZOA. 

I. Malaria and Amoebic Dysentery (v. Acute Infections). 

II. The Trypanosoma. — This is a protozoon found by Gruby (1843) 
in frogs, Doflein (1845) in rats, and later in many other animals, 
and in man (Nepvue, 1890-98). There are many species. It is leech- 
shaped; its body is granular, measures 13 to 25, by 2 to 4/!, and contains 
a nucleus and micronucleus (centrosome) ; on one side and attached 
to an "undulating membrane" is a solitary flagellum by which the 
parasite moves. In cool and moist hanging-drop perparations they 
may live for a month and a half. Novy and McNeal cultivated the 
T. Lewisi and Brucei on agar and defibrinated blood. Infection is 
carried by the tsetse-fly, flea, louse, mosquito and ticks. In man the 
two clinical forms (v. i.) of trypanosomiasis are conveyed by the 
tsetse-fly (Glossina palpalis) or possibly by bites from infected fats. 
Animals may be infected during coitus, by subcutaneous inoculation, 
or by the stomach. 

1. Trypanosoma fever was first described by Nepveu. The atrium 
may be present as an inflamed bite, or the history of a bite may be 
obtained. Parasites in the blood may cause no symptoms; they occur 
in the plasma and not in the corpuscles; some anaemia is present and 
the large lymphocytes are increased in number (up to 20 per cent.), 
but the eosinophiles show no increase. Fever is irregular, subcontin- 
uous or remittent; it does not react to quinine; it lasts from three 
days to three weeks. An erythematous eruption is almost constant. 
(Edema, particularly of the lower lids, weak and rapid pulse, pros- 
tration, splenic tumor and enlargement of the lymph glands which con- 
tain the parasite, usually occur. In treatment, arsenic is apparently 
most helpful, while quinine is without effect. Careful feeding and 
cardiac stimulation are indicated. The patient, as is the case in yellow 
fever, should be so screened that flies can neither convey fresh infection 
to him nor bite him, and thus infect others. 



DISEASES CAUSED BY PROTOZOA 1277 

2. Sleeping sickness or African lethargy, which is endemic in Cen- 
tral x4frica, is due to localization of the same trypanosoma parasite 
in the nervous system, causing a diffuse meningo-encephalomyelitis 
(Mott). Negroes are chiefly affected but Caucasians may contract the 
disease. 

The incubation is long, and may possibly cover years. Incipient 
symptoms are those of the trypanosoma fever (v.s.) or less often there 
are preliminary psychical phenomena, as epileptiform convulsions, 
melancholia or mania. Somnolence develops, from which at first the 
patient can be aroused, but which later develops into profound lethargy. 
The parasite is found in the blood (in 92 per cent., Bruce) and in 60 
per cent, of cases in the cerebrospinal fluid when withdrawn by lum- 
bar puncture (Castellani), or in 100 per cent. (Bruce). Malnutrition, 
decubitus, and sometimes secondary infections develop, and after the 
convulsions deepen into coma, the patient dies. The course lasts 
from months to several years. Treatment is unavailing. More than a 
quarter of a million people died in Uganda in the last few years from 
this affection. 



INDEX 



Abdominal pain, causes of, 668 
in pneumonia, 141 
in typhoid fever, 32 
Aboulia, hysterical, 1186 
Abortion in typhoid fever, 38 
Abscess of brain, 1013 

differentiation of, from brain 
tumor, 1008 
cold, 311 
extradural, differentiation of, from 

brain abscess, 1007 
of liver, 707 

amcebic, 708 

dysentery, 230 
cholangitic, 708 
differentiation of, from cancer, 
713, 724 
from pleurisy, 559 
from portal cirrhosis, 724 
pylephlebitis 707 
septic, 707 
solitary, 708 
tropical, 708 
in typhoid fever, 31 
of lung, 526 

differentiation of, from gan- 
grene, 530 
pneumonic, 149 
in typhoid fever, 36 
perinephric, 812 
of spleen, 883 
subphrenic, 756 

differentiation of, from pleu- 
risy, 559 
from pneumothorax, 566 
of thymus gland, 897 
Acetonuria, diabetic, 909, 918 

test for, 909 
Achylia gastrica, 609, 644 
etiology of, 609 
pathology of, 609 
prognosis of, 610 
symptoms of, 609 
treatment of, 610 
Achlorhydria in gastric cancer, 633 
"Acid-fast" bacilli, 304 
Acidosis, diabetic, 908, 910, 912, 918, 918 
Acoria, 648 
Acrodynia, 207 



Acromegaly, 898 
course of, 899 
diagnosis of, 900 
differentiation of, 900 
etiology of, 898 
prognosis of, 899 
symptoms of, 898 
treatment of, 901 
Acroparesthesia, 1235 
Actinomycosis, 256 
diagnosis of, 259 
etiology of, 256 
forms of, 257 
incubation in, 257 
of liver, 258 
parapleuritis, 554 
symptoms of, 259 
treatment of, 260 
Adams-Stokes syndrome, 443, 457 
Addison's anaemia. See Pernicious An- 
aemia 
disease, 877 

course of, 880 
diagnosis of, 880 
differentiation of, from argyria, 
880 
from icterus, 880 
from other pigmentations, 

880 
from pellagra, 880 
etiology of, 877 
symptoms of, 878 
treatment, 881 
Adenia, 860 
Adenitis, bronchial, 339 

cervical, 338 
Adenoids, 587 
Adiamorrhysis, 962 
Adipose ascites, 765, 766 
Adiposis dolorosa, 938 

pathology of, 938 
symptoms of, 938 
treatment of, 939 
Adiposity, 936 

Adrenal glands, diseases of, 877 
Adrenals, syphilis of, 277 
iEgophony, 145 
Aerophagia, 645 
African lethargy, 1277 
Agraphia, 948, 952 
Ague-cake, in malaria. 119 

1279 



1280 



INDEX 



Ainhum, 1237 
Albumin in urine, 799 
Albuminuria, 799 
albumose, 801 
Bence- Jones, 801 
diabetic, 908 
diagnosis of, 802 
diphtheritic, 168 
etiology -of, 800 
genuine, 799 
globulin, 801 
in malaria, 120 
mucin, 801 
in nephritis, 769 
nucleo-albumin, 801 
peptone, 801 
in pneumonia, 147 
prognosis of, 802 
renal, 799 
rheumatic, 192 
scarlatinal, 89 
spurious, 799 
syphilitic, 276 
tests for, acetic acid, 801 
boiling, 800 
ferro cyanide, 801 
Jolles', 801 
nitric acid, 801 
Spiegler's, 801 
in tuberculosis, 336 
in typhoid fever, 37 
in yellow fever, 217 
Albumose, tests for, 801 
Alcohol, coma from, 975 
Alcoholic cirrhosis of liver, 695 
Alcoholism, acute, diagnosis of, 1241 
symptoms of, 1241 
treatment of, 1242 
chronic, prognosis of, 1243 
symptoms of, 1242 
treatment of, 1243 
delirium tremens, 1244 
differentiation of, 1026 
Alexia, 946, 947, 949, 950 
Alimentary tract, tuberculosis of, 346 
Alkalies. See Ulcer of Stomach, also 

Hyperchlorhydria. 
Alkaptonuria, 808 
Allantiasis, 1251 
Allocheiria, tabetic, 1117 
Amaurosis, 1149 

with idiocy, 1137 
Amblyopia, 1149 
Ammoniaemia, 811 
Ammonium, in urine, 908 
Amoeba dysenteriae, 227 
Amoebic dysentery, 227 

complications of, 229 
issues of, 229 
pathology of, 229 
symptoms of, 228 
treatment of, 231 
Amyloid degeneration of kidneys, 793 
of spleen, 882 
in tuberculosis, 336 



Amyloid kidney, differentiation of, from 
_ nephritis, 796, 797 
liver, differentiation of from cancer, 
713, 724 
from portal cirrhosis, 701, 
724 
Anaemia, aplastic 846 
of brain, 961 
in cirrhosis of liver, 699 
classification of, 831 
in heart disease, 418 
infantum, pseudoleukaemica, 863 
lienalis, 860 
lymphatica, 860 
in nephritis, 770 
pernicious, 839 
course of, 844 
diagnosis of, 844 
differentiation of, from bone 
tumors, 845 
from carcinoma of stom- 
ach, 845 
from chlorosis, 845 
from parasitic anaemia, 845 
from secondary anaemia, 
845 
etiology of, 839 
prognosis of, 844 
symptoms of, blood, 839, 840 
circulation, 841 
digestion, 842 
haemolymph glands, 842 
metabolism, 841 
nervous, 843 
sexual, 843 
-skin, 841 
subjective, 841 
treatment of, 846 
pseudopernicious, of children, 863 
secondary, post-hemorrhagic, acute, 
847 
etiology of, 847 
symptoms of, 847 
prognosis of, 848 
treatment of, 848 
chronic, etiology of, 849 
differentiation of, 845 
symptoms of, 849 
treatment of, 850 
of spinal cord, 1083 
splenic, 864, 883 

splenica infettiva dei bambini, 863 
tuberculous, 311, 323 
Anaesthesia, dissociated, 1110 
Anarthria, 948, 959 
Anasarca in nephritis, 770 
Aneurysm, abdominal, 481 
diagnosis of, 481 
prognosis of, 482 
signs of, 481 
symptoms of, 481 
treatment of, 482 
of aorta, 470 
of brain, 989 
cceliac, 482 



IXDEX 



1281 



Aneurysm, gastric, 4S2 
of heart, 446 
hepatic, 482 
intracranial, 989 

diagnosis of, 990 
etiology of, 989 
pathology of, 990 
symptoms of, 990 
treatment of, 990 
mesenteric, 482 
miliary in cerebral hemorrhage, 965, 

966" 
renal. 482 
splenic, 482 
syphilitic, 278, 285 
thoracic, 470 

death mechanism of, 479 
diagnosis of, 478 
differentiation of, 479 
etiology of, 470 
pathology of, 471 
physical signs of, 473 

heart changes, 475 
respiratory changes, 

476 
sympathetic, 478 
vascular changes, 475 
prognosis of, 479 
symptoms of, 472 
treatment of, 480 
Angina abdominalis, 460, 469 
cruris, 460, 468 
erysipelatous, 106 
in influenza, 178 
Ludovici, 580 
pectoris, 458 

diagnosis of, 460 
differentiation of, 461 
etiology of, 458 
pathology of, 458 
prognosis of, 461 
symptoms of, 459 
treatment of, 461 
phlegmonosa, 583 
syphilitic, 270 
in typhoid fever, 30 
ulceromembranosa, 583 
Vincent's, 583 
Angioneurotic crisis, differentiation of, 
from gall-stones, 733 
haematuria, 802 
oedema, 1236 
Angiosclerosis, 463 
Anguillula intestinalis, 1274 
Ankylosis, rheumatic, 193 
Ankylostoma duodenale, 1269 
Anorexia, 647 

in tuberculosis, 335 
Anosmia, 1146 
Anthracosis of lungs, 522 
Anthrax, 239 

bacteriology of, 239 

differentiation of, from typhoid 

fever, 42 
etiology of, 239 
external, 240 
81 



Anthrax, external, diagnosis of, 241 
differentiation of, 241 
prognosis of> 241 
site of, 240 
symptoms of, 240 
treatment of, 242 
internal, 242 

intestinal, 242 

diagnosis of, 243 
symptoms of, 242 
respiratory, 243 

symptoms of, 243 
treatment of, 244 
septicaemia, 244 
Antitoxin, in diphtheria, 172 

in tetanus, 251 
Anuria, renal colic causing, 819 

in yellow fever, 217 
Aorta, aneurysm of, 470 
arteriosclerosis of, 468 
atheroma of, 468 
dilatation of, intermittent, 482 
embolism of, 483 
inflammation of, 483 
rupture of, 483 
syphilis of, 278 
thrombosis of, 484 
tuberculosis of, 356 
Aortic insufficiency, 401 
etiology of, 401 
mechanism of, 402 
physical signs of, 402 

auscultation, 404 
inspection, 402 
palpation, 403 
percussion, 403 
treatment of, 423 
stenosis, 405 

diagnosis of, 407 
differentiation of, 407, 412 
etiology of, 405 
mechanism of, 406 
physical signs of, 406 

auscultation, 406 
inspection, 406 
palpation, 406 
percussion, 406 
symptoms of, 406 
treatment of, 423 
Aortitis, acute, 483 
syphilitic, 278 
Aphasia, amnestic, 950, 952 
auditory, 949, 952 
in cerebral embolism, 983, 988 
hemorrhage. 971, 988 
thrombosis,' 986, 988 
conduction, 952 
differentiation of, 952 
localization, 947, 948, 952 
motor, 948, 952 
sensory, 949, 952 
visual, 950, 952 
Aphthae epizootics, 375 
Aphthous fever, 375 
stomatitis, 575 
Aplastic anaemia, 846 



1282 



INDEX 



Apneumatosis of lungs, 524 
Apoplectiform attacks in paretic de- 
mentia, 1024 
bulbar paralysis, 1033 
seizures, in multiple sclerosis, 1106 
Apoplexy, 965 
cardiac, 449 
differentiation of, 988 
fulminating, 969 
habitus, 965 
ingravescent, 969 
Appendicitis, 664 

actinomycotic, 258 
in aged, 668 
bacteriology of. 664 
in children, 668 
complications of, abscess, 667 
chronic changes, 668 
necrosis, 666 
peritonitis, 667 
ulceration, 666 
diagnosis of, 668 
differentiation of, 668 

from gall-stones, 733 
from pneumonia, 141 
etiology of, 664 
larvata, 668 
pathology of, 665, 666 
prognosis of, 668 
symptoms of, 665 
early, 665 
late, 666 
remote, 668 
treatment of, 669 
tuberculous, 349 
typhoid, 32 
Appendix vermiformis, cancer of, 678 
foreign bodies in, 664 
inflammation of, 664 
typhoid ulcers of, 31, 32 
Appetite, disturbance of sense of, 647 
Aprosexia, 587 
Argyll-Robertson pupil, 1118 

in paretic dementia, 1024 
Argyria, differentiation of, from Addi- 
son's disease, 880 
Arrhythmia, 457 
Arsenical poisoning, 1251 
Arterial tension, in contracted kidney, 

781 
Arteries, diseases of, 463 

syphilitic endarteritis of, 277 
Arteritis, 483 

pneumococcic, 148 
rheumatic, 196 
in typhoid fever, 25 
Arteriocapillary fibrosis, 463 
Arteriosclerosis, 463 
diagnosis of, 466 
differentiation of, from syphilitic 

endarteritis, 285 
etiology of, 463 
pathogenesis of, 464 
pathology of, 464 
prognosis of, 469 
symptoms of, 466 



Arteriosclerosis, treatment of, 470 

tuberculous, 311 
Artery of hemorrhage, 965 
Articular rheumatism, acute, 190 
Arthritis deformans, 926 
diagnosis of, 929 
differentiation of, 929 

from articular infections, 

930 
from chronic fibrous rheu- 
matism, 930 
from gout, 929 
from hsemophilic arthritis, 

930 
from syphilitic arthritis, 

930 
from syringomyelic joints, 

930 
from tabetic arthropathies, 

930 
from tuberculous arthritis, 
929 
etiology of, 926 
pathology of, 927 
treatment of, 930 
types of, 927 

diffuse, acute, 927 

chronic, 927 
Heberden's nodes, 929 
juvenile, 929 
monarticular, 928 
partial, 928 
vertebral, 928 
divitum, 921 
pauperum, 921 
pneumococcic, 149 
rheumatic, 192 
in typhoid fever, 29 
Arthropathies, syringomyelic, 1111 

tabetic, 1119 
Ascaris lumbricoides, 1264 
Ascites, adipose, 765, 766 
in cancer of liver, 712 
chyliform, 766 
chylous, 765 
in cirrhosis of liver, 697 
diagnosis of, 760 

differentiation of, from hepatic 
cirrhosis, 764 
from perihepatitis, 764 
from peritoneal cancer, 763, 764 
from serous peritonitis, 761, 

762, 763 
from tuberculous peritonitis, 
761, 762, 763 
etiology of, 759 
in heart disease, 421 
in pericarditis adhesiva, 387 
symptoms of, 759 
treatment of, 765 
Aspergillus, pseudotuberculosis, 307, 332 
Associated movements in apoplexy, 974 
Association, centres for, 947 
Astasia-abasia, hysterical, 1188 
Asthma, bronchial, 506 

diagnosis of, 508 



INDEX 



1283 



Asthma, differentiation of, 508 
etiology of, 506 
pathogenesis of, 507 
prognosis of, 509 
symptoms of, 507 
treatment of paroxysm, 509 
of tendency, 510 
cardiac, 509 
Millar's, 897 
thymic, 897 

periodic, differentiation of, from 
whooping-cough, 185 
Asthenia in tuberculosis, 335 
Asthenic bulbar paralysis, 1032 
Ataxia, cerebellar, 960 
cortical, 946 
crus lesion causing, 957 
Friedreich's, 1135 
hereditary, 1135 

cerebellar, 1137 
diagnosis of, 1137 
etiology of, 1135 
pathology of, 1136 
prognosis of, 1137 
symptoms of, 1136 
treatment of, 1137 
pons lesions causing, 958 
in tabes, 1116 
Atelectasis of lungs, acquired, 525 

congenital, 524 
Atheroma, 463 

of aorta, 468 
Athetosis, in cerebral infantile paralysis, 
998 
posthemiplegic, 974, 975 
Atony of stomach, 610 
Atrophia hepatis fusca, 692 
Atrophic cirrhosis of liver, 695 
Atrophy of brain, 1028 
of heart, 441 
hemifacial, 1157 
of liver, acute yellow, 692 
progressive spinal, 1128 
of stomach, 609 
of testicles in mumps, 189 
Aura, epileptic, 1202 
Autumnal fever, 19 



Babinski's sign, 972 
Baccelli's sign in pleurisy, 549 

in pneumonia, 145 
Bacilluria, treatment of, 55 

in typhoid fever, 37 
Bacillus aerogenes encapsulatus, 390 
in pneumothorax, 563 

anthracis, 239 

botulinus, 1251 

diphtheria?, 159 

dysenterise, 225 

Klebs-Loefner, 159 

leprae, 304 

mallei, 244 

Oppler-Boas, 634, 635 



Bacillus tetani, 247 
tuberculosis, 304 
typhosus, 17 
Bacterisemia, septic affections, 131 
Balne's cough, 588 
Bamberger's sign in pericarditis, 383 
Banting's cure, 937 

Banti's disease, differentiation of, from 
portal cirrhosis of liver, 

702 
from pseudoleukemia, 864 
Barlow's disease, 872 

diagnosis of, 873 
etiology of, 872 
prognosis of, 873 
symptoms of, 872 
treatment of, 873 
Basedow's disease, 888 
Baths in typhoid fever, 49 
Baume's law, 295 
Becker's sign, 890 
Bednar's plaques, 574 
Bedsores in typhoid fever, 24 
causes of, 55 
treatment of, 55 
Bence-Jones' albumose, 801 
Beriberi, 236 

diagnosis of, 238 
distribution of, 236 
etiology of, 236 
prognosis of, 238 
symptoms of, 237 
treatment of, 238 
types of, 238 
Beta-oxybutyric acid, 908, 910 
Biernacki's sign, 1117 
Bile, flow of, 651 

Bile-ducts, obliteration of, congenital, 
741 
tumors of, 742 
Bile-vessels, diseases of, 725 
Bilharzia disease, 1275 
Biliary cirrhosis of liver, 695, 704 

differentiation of, from 
portal, 705, 724 
colic, 730, 733 
Bilious typhoid, 61 
Bilirubin, test for, in stools, 653 
Biot's breathing, 1047 
Black death, 219, 223 
smallpox, 71 

water fever, 118, 121, 125 
Bladder, tuberculosis of, 352 
"Bleeders," 874 
Blood, diseases of, 831 
in pneumonia, 145 
pressure in typhoid fever, 24 
typhoid, bacilli in, 27 
in urine, 802 
Bloodvessels, syphilis of, 277 

tuberculosis of, 356 
Bones, syphilis of, 292 

tuberculosis of, 357 
Bothriocephalus latus, 1261 
Botulism, 1251 
Boulimia. 648 



1284 



INDEX 



Bowels, intussusception of, 670 
strangulation of, 671 
stricture of, 673 

diagnosis of, 675 
symptoms of, 673 
treatment of, 676 
in typhoid fever, hemorrhage from, 
33 
perforation of, 34 
treatment of, 53 
Brachial neuritis, 1178 
Brachycardia, 456 
Bradycardia, 456 
etiology of, 456 
prognosis of, 457 
treatment of, 457 
Brain, abscess of, 1013 

diagnosis of, 1017 
differentiation of, 1017 

from extradural abscess, 

1017 
from otitis, 1017 
from serous meningitis, 

1017 
from sinus thrombosis, 

1017 
from suppurative meningi- 
tis, 1018 
from tumor, 1008 
etiology of, 1013 
pathology of, 1013 
prognosis of, 1019 
symptoms of, 1015 
treatment of, 1019 
actinomycosis of, 259 
arteriosclerosis of, 468 
atrophy of, 1028 
cancer of, 1001 
circulatory diseases of, 961 
anaemia, 961 
aneurysms, 989 
congestion, 962 
embolism, 979 
hemorrhage, 965 
hyperemia, 962 
oedema, 964 

thrombosis (arterial), 985 
cysts of, 1001 
degeneration of, 1027 

lacunar, 987 
diffuse lobar sclerosis of, 997, 1028 
diseases of, 941 

differentiation of, from serous 
meningitis, 1055 
glioma of, 1000 
gumma of, 1000 
hemorrhage of, 449 
in syphilis, 285 
hypertrophy of, 1028 
inflammation of, 1010 
lesions of, in diphtheria. 167 
localization of, 941 
sarcoma of, 1000 
"softening" of, 979, 985, 1020 
chronic, 1027 
syphilitic, 284 



Brain, syphilis of, 281 

differentiation of, from paretic 
dementia, 1025 
from tabes dorsalis, 1122 
tuberculosis of, 346, 999 
tumors of, 999 

classification of, 999 
course of, 1009 
diagnosis of, 1007 
differentiation of, 1007, 1008 
from brain abscess, 1008 
from chronic meningitis, 

1009 
from multiple sclerosis, 

1009 
from uraemia, 1007 
etiology of, 999 
localization of, 1001, 1003 
pathology of, 999 
prognosis of, 1009 
symptoms of, 1001 
treatment of, 1009 
Brand bath in typhoid fever, 49, 50 
Breasts, chancre of, 294 
gumma of, 294 
syphilis of, 294 
Breathing, metamorphosing, 326 
Bremer's test of diabetic blood, 912 
Bright's disease, chronic, 774 
Briquet's syndrome, 1190 
Broadbent's sign, 388 
Broca's convolution, 948 
Brodie's joints, 1200 
Bromatotoxismus, 1251 
Bromism, differentiation of, 1026 
Bronchi, dilatation of, 502 
diseases of, 495 
inflammation of, 495 
foreign bodies in, 505 
stenosis of, 504 
stones in, 506 
syphilis of, 280 
Bronchial adenitis, 339 
asthma, 506 
breathing in pleurisy, 549 

in pneumonia, 145 
casts in pneumonia, 142 
glands, anthracosis of, 523 

tuberculosis of, 339 
stenosis, 505 

diagnosis of, 505 
etiology of, 505 
symptoms of, 505 
treatment of, 506 
ulcers, syphilitic, 280 
Bronchiectasis, 502 

complications of, 503 

diagnosis of, 503 

differentiation of, from gangrene of 

lung, 530 
pathology of, 502 
physical signs of, 503 
symptoms of, 502 
treatment of, 504 
Bronchitis, acute, 495 

etiology of, 495 



INDEX 



1285 



Bronchitis, acute, symptoms of, 496 
treatment of, 497 
capillary, 518 
chronic, 498 

diagnosis of, 499 
etiology of, 498 
pathology of, 498 
prognosis of, 499 
symptoms of, 498 
treatment of, 499 
differentiation of, from influenza, 

181 
fibrinous, 500 

diagnosis of, 501 
etiology of, 500 
prognosis of, 501 
symptoms of, 501 
treatment of, 501 
in heart disease, 419 
in influenza, 178 
mucinosa, 501 
pseudomembranacea, 501 
putrid, 499 

differentiation of, from gan- 
grene of lung, 530 
syphilitic, 280 
tuberculous, 311, 333 
in typhoid fever, 35 
in whooping-cough, 184 
Bronchophony, 145 
Bronchopneumonia, 515 
bacteriology of, 516 
diagnosis of, 518 

differentiation of, from lobar pneu- 
monia, 519 
from tuberculosis, 519 
diphtheritic, 168 
etiology of, 515 
in influenza, 179 
issues of, 518 
measles as cause of, 99 
pathology of, 516 
physical findings of, 516 
prognosis of, 518, 519 
symptoms of, 516 
treatment of, prophylactic, 519 

symptomatic, 519 
types of, special, capillary, 518 
disseminated, 518 
generalized, 518 
in whooping-cough, 184 
Bronchorrhcea, 498 
Brown-Sequard's paralysis, 1086 
prognosis of, 1088 
symptoms of, 1086 
Bryson's sign, 890 
Bruit d' arain in pneumothorax, 564 
de diable, 833 
de pot fel6, 326 
Bubonic plague, 219 
Bulbar paralysis, apoplectiform, 1033 
asthenic, 1032 
chronic, 1029 

diagnosis of, 1031 
etiology of, 1029 
pathology of, 1029 



Bulbar paralysis, chronic, prognosis of, 
1032 
symptoms of, 1030 
treatment of, 1032 
complicated, by progressive 
muscular atrophy, 1031 
syringomyelia, 1111 
Bundle of His, 457 _ 
Burr bath in typhoid fever, 49, 50 



Cat's tongue, scarlatinal, 88 
Cachexia in cancer of liver, 712 
lienalis, 860 
lymphatica, 860 
scorbutic, 870 
strumipriva, 895 
thyreopriva, 895 
Cachexie pachydermique, 894 
Caecum, tuberculosis of, 349 
Caisson paralysis, 1085 

etiology of, 1085 
pathology of, 1085 
prognosis of, 1085 
treatment of, 1086 
Calcium calculus, 818 

chloride, in hemorrhages, 875 
Calculus, calcium, 818 
cystin, 818 
of lung, 320 
oxalate, 818 
of pancreas, 747 
phosphatic, 818 
renal, 817 

in gall-stones, 733 
of ureter, 822 
uric acid, 817 
xanthin, 818 
Cancer of appendix vermiformis, 678 
of brain, 1001 
of gall-bladder, 741 

differentiation of, from 
gall-stones, 734, 735 
of intestines, 677 
of liver, 711 

differentiation of, from biliary 
cirrhosis, 706, 724 
from portal cirrhosis, 701, 
702, 724 
primary, 711 
of oesophagus, 595 
of pancreas, differentiation of, from 

gall-stones, 750 
of peritoneum, 758 
of rectum, 677, 679 
renal, 822 
of stomach, 629 
of thyroid gland, S87 
of vertebrae, 1075 
Cancrum oris, 576 
Capsular cirrhosis of liver, 695 
Caput Medusae, 69s 
Carbohydrates, physiology of, 903 
Carbuncle in plague, 221. 222 



1286 



INDEX 



Carbuncle, simple, differentiation of, 

from anthrax, 241 
Cardiac apoplexy, 449 
asthma, 509 

insufficiency of stomach, 646 
spasm, 644 
Cardialgia, 647 
Cardiogmus, 451 
Cardiomegaly, 899 
Cardiopamius, 451 
Cardiospasm, oesophagus, 593 
Caries of vertebra?, 1071 
Carphologia in typhoid fever, 28 
Casts in pneumonia, bronchial, 142 
fibrin, 142 
urinary, 769 

origin of, 776 
significance of, 776 
Catarrhal diphtheria, 163 

stomatitis, 573 
Catarrhus aestivus, 486 
Cauda equina, lesions of, 1065 
Cellulitis, differentiation of, from ery- 
sipelas, 107 
Centrum ovale, localizing symptoms, 951 
Cerebellar, ataxia, 960 
causes of, 960 
differentiation of, 960 
vertigo, 960 
Cerebellum, localizing symptoms of, 959 
Cerebral embolism, 979 

diagnosis of, 984 
differentiation of, from cerebral 
hemorrhage, 988 
thrombosis, 988 
etiology of, 979 
location of. 982 
basilar, 984 
cerebral, anterior, 983 

posterior, 983 
internal carotid, 983 
Sylvian artery, 982 
vertebral, 984 
pathology of, 980 
prognosis of, 984 
symptoms of, 981 
treatment, 984 
hemorrhage, 965 
cerebellar, 977 
cortical, 976 
crus, 977 
diagnosis of, 449 
of coma, 975 
of hemiplegia, 976 
of location, 976 
differentiation, from cerebral 
embolism, 988 
from cerebral thrombosis. 
98S 
etiology of, 965 
locations of, 966 
medulla, 977 
pathology of, 965 
pons, 977 
prognosis of, 977 
symptoms of, 968, 975, 988 



Cerebral hemorrhage, treatment of 
chronic stage, 979 
of insult, 978 
prophylaxis, 978 
of reaction, 979 
ventricular, 976 
localization, 941 

centrum ovale, 951 
cerebellum, 959 
cerebral peduncle, 956 
corpora quadrigemina, 955 
corpus striatum, 954 
crus, 956 

frontal cortex, 947 
internal capsule, 951 
motor cortex, 941 
occipital cortex, 946 
optic thalamus, 954 
parietal cortex, 946 
pons, 957 

temporal cortex, 947 
nerves, syphilis of, 282 
paralysis, infantile, 994 

diplegic form, 996 
hemiplegic form, 995 
pneumonia, 152 
rheumatism, 194, 199 
thrombosis, 985 

diagnosis of, 987 
differentiation of, from cerebral 
embolism, 988 
hemorrhage, 988 
from lacunar degeneration, 
987 
etiology of, 985 
localization of, basilar, 987 
cerebral anterior, 987 

posterior, 987 
Sylvian artery, 986 
vertebral, 987 
pathology of, 985 
prognosis of, 989 
symptoms of, 985 
treatment of, 989 
Cerebrasthenia, 1194 
Cerebritis, 1010 
Cerebrospinal fever, 175 

meningitis, epidemic, 1045 
Cervical adenitis, 338 
Cervix, syphilis of, 291 
Chalicosis of lungs, 523 
Chancre. See Syphilis 
Chancroid, 266 
Charcot-Levden crystals, 508 
Charcot's disease, 1126, 1119 
Cheese poisoning, 1252 
Chiasm, optic, 1147 
Chicken-breast, 588 

rhachitic, 933 
Chickenpox, 81 

complications of, 83 
diagnosis of, 83 
differentiation of, 83 
from eczema, 83 
from miliaria, 83 
from pemphigus, 83 



INDEX 



1287 



Chickenpox, differentiation of, from 
smallpox, 74 
from syphilis, 83 
etiology of, 81 
sequels of, 83 
symptoms of, 81 
Chills, in typhoid fever, 21, 24 
Chlorides, absence of, in pneumonic urine, 

146 
Chloroma, 858 
Chlorosis. 831 

complications of, 834 
course of, 835 
diagnosis of, 835 

differentiation of,, from pernicious 
ansemia, 845 
from secondary ansemia, 845 
etiology of, 831 
prognosis of, 835 
symptoms of, 832 
treatment of, 836 
dietetic, 838 
iron, 836 
prophylactic, 836 
specific, 836 
Choked disk, in brain tumor, 1002, 1007, 

1008 
Cholaemia, 693, 699, 727 
Cholangitis, catarrhal, 739, 741 
differentiation of, 734, 735 

from gall-stones, 734, 735 
suppurative, 739 
Cholecystitis, 738 

differentiation of, from cancer, 734, 
735 
from gall-stones, 734, 735 
etiology of, 738 
following typhoid fever, 31 
prognosis of, 739 
symptoms of, 739 
treatment of, 739 
Cholelithiasis. See Gall-stones, 728 
Cholera, Asiatic, 207 

bacteriology of, 207 
comma bacillus, 207 
complications of, 210 
diagnosis of, 211 
dissemination of, 207 
predisposition to, 208 
prognosis of, 212 
symptoms of, 209 
treatment of, 212 
infantum, 659 
nephritis, 771 
nostras, 211 
Cholerine, 211 

Chondrodystrophia fcetalis, 894 
Chondroma of thyroid gland, 887 
Chorea, acute, 1211 

course of, 1214 
diagnosis of, 1214 
etiology of, 1211 
pathology of, 1211 
prognosis of, 1214 
symptoms of, 1212 
treatment of, 1216 



Chorea, acute, types of, 1214 

in cerebral infantile paralysis, 998 

chronic, 1215 

electric, 1216 

endocarditis from, 397 

habit, 1215 

Huntindon's, 1215 

posthemiplegic, 974, 975 

rheumatic, 192, 199 
Choreiform affections, 1210 
Choroidal tubercles, 316, 1051 
Choroiditis, syphilitic, 288 
Chyle in urine, 806 

vessels, disease of, 691, 765 
Chyliform ascites, 766 

pleurisy, 553 
Chylothorax, 568 
Chylous ascites, 765 
Chyluria, 806 

parasitic, 1272 
Chvostek's sign, 1219 
Cirrhosis of liver, 695 

in heart disease, 421 
tuberculous, 311 

ventriculi, 609 
Cirsomphalos, 698 
Cladothrix asteroides, 259 
Claudication intermittente , 468 
Coccygodynia, 1232 
Colectasia, 682 
Colic, biliary, 730 

lead, differentiation of, from gall- 
stones, 733 

mucous, differentiation of, from gall- 
stones, 733 

renal, 819, 821 

differentiation of, from gall- 
stones, 733 
Colica mucosa, 654 

etiology of, 654 
symptoms of, 654 
treatment of, 654 

pictonum, 1247 
Colitis, membranacea, 654 

mucosa, 654 
Collapse in pneumonia, 146 

in typhoid fever, 21, 25, 47 
Collar of brawn in scarlatina, 90 
Colles' law, 295 

Colon bacillus. See Septic Affections, 
130, 133 

dilatation of, 682 

prolapse of, 680, 681 
Coloptosis, 680 
Coma, alcoholic, 975 

apoplectic, 975, 988 

cardiac, 975, 976 

diabetic, 910, 918, 976 

epileptic, 1203 

opium, 975 

in pernicious malaria, 124 

uraemic, 976 

vigil in typhoid fever, 28 
Comma bacillus, 207 
Common bile-duct, gall-stones in. differ- 
entiation of, 750 



1288 



INDEX 



Concato's disease, 758 
Concretio pericardii, 387 
Concussion of spinal cord, 1088 
Congenital heart disease, 430 

tuberculosis, 309 
Congestion of brain, 962 
of kidney, 791 
of liver, arterial, 720 

passive, 721 
of lungs, acute, 534 
passive, 534 
Conjugate deviation, 958 
in apoplexy, 970 
Conjunctiva, syphilis of, 287 
Constipation, 685 

in colica mucosa, treatment of, 655 
etiology of, 685 
symptoms of, 685 
treatment of, cathartics, 688 
diet, 686 
enemata, 688 
exercise, 687 
massage, 687 
posture, 687 
in typhoid fever, treatment of, 52 
Constitutio lymphatica, 886 
Constitutional diseases, 903 
Consumption, 318 
Contracted kidney, 775, 778, 784 
Contractures, in apoplexy, 973 

hysterical, 1188 
Conus medullaris, lesions of, 1064 
stenosis, 405, 446 
in syphilis, 277 
Convulsions in brain tumor, 1002, 1007 
in cerebral embolism, 983, 988 
hemorrhage, 970 
thrombosis, 987, 988 
epileptic, 1203 
infantile, 1209 

etiology of, 1209 
symptoms of, 1210 
treatment of, 1210 
Jacksonian, 1004, 1007 
in typhoid fever, 28 
in whooping-cough, 184 
Coprostasis, obstructing bowel, 674 
Cor bovinum, 402, 439 

villosum, 378 
Cornea, syphilis of, 287 
Coronary disease, arteritis, 447, 450 

atheroma, 447, 450 
Corpora oryzoidea, 357 

quadrigemina, localizing symptoms, 
955 
Corpulence, 936 
Corpus striatum, localizing symptoms, 

954 
Corrigan's disease, 401 
Corset liver, 720 

Cortex, cerebral, localization, 941 
Coryza, 485 

differentiation of, from influenza, 

181 
syphilitic, 297 
in typhoid fever, 35 



Costa fluctuans decima, 680 

Courvoisier's law, 732 

Cracked pot resonance, in pneumonia, 

144 
Craniotabes, rhachitic, 932, 934 
Cranium progenium, 900 
Crepitant rale, 145 

diseases where present, 145 
in pneumonia, 145 
Cretinism, 893 

diagnosis of, 894 
etiology of, 893 
symptoms of, 893 
Crie hydrencephalique, 1046 
Croup, differentiation of, from whooping- 
cough, 185 
diphtheritic, 165 
false, 491 

differentiation of, from whoop- 
ing-cough, 185 
Croupous enteritis, 655 
Cms, localizing symptoms, 956 
Cryoscopy, 780 

Crystals, Charcot-Leyden, 508 
Culex fasciata, 213 
Cyanosis in heart disease, 419 
tuberculous, 315 
with polycythemia, 885 
with splenomegaly, 885 
Cyclaster scarlatinalis, 84 
Cycloplegia, 1150 
Cylinduria in pneumonia, 147 
Cynanche gangrceneuse, 580 
Cystic duct, in gall-stones, 731 

kidney, etiology of, 826 
Cysticercus, of brain, 1001 

cellulosae, 1259 
Cystin calculus, 818 

Cystitis, differentiation of, from pyeli- 
tis, 811 
in typhoid fever, 37 
Cystosoma, haematobium, 1275 
Cysts of brain, 1001 
of liver, 714 

echinococcus, 714, 716 
multilocular, 716 
unilocular, 714 
hydatid, differentiation of, from 

portal cirrhosis, 724 
non-parasitic, 715 
of pancreas, 748 
of spleen, 883 
of thymus gland, 897 
of thyroid gland, 887 
Cytodiagnosis, 551 

in lumbar puncture, 1053 
Cytorytes vaccinise, 77 
variolar, 64 



Damoiseau's curve in pleurisy, 546 
Dandy-fever, 205 
Deafness, 1164 

cortical, 947, 948 



INDEX 



1289 



Degeneratio renum polycystica, 826 
Degeneration of brain, 1027 
lacunar, 987 
of kidneys, amyloid, 793 

cystic, 826 
of pyramidal tracts, 967 
of spinal cord, ascending, 1064 

descending, 1060, 1061 
of spleen, amyloid, 882 
of suprarenal glands, 881 
Delirium cordis, 458 

in fevers, treatment of, 54, 80 
tremens, diagnosis of, 1244 
etiology of, 1244 
prognosis of, 1244 
symptoms of, 1244 
treatment of, 1245 
Dementia paralytica, 1020 
diagnosis of, 1025 
differentiation of, from alcohol- 
ism, 1026 
from brain sclerosis, 1025 

tumor, 1026 
from bromism, 1026 
from mania, 1026 
from multiple sclerosis, 

1025 
from neurasthenia, 1026 
from pachymeningitis, 

1026 
from plumbism, 1026 
from senile dementia, 1025 
from syphilis, 1025 
etiology of, 1020 
pathogenesis of, 1020 
pathology of, 1020 
prognosis of, 1026 
symptoms of, general, 1021 
treatment of, 1027 
paretic, 1020 
senile, 1026 
Dengue, 205 

complications of, 206 
diagnosis of, 206 
differentiation of, 207 
from acrodynia, 207 
from influenza, 207 
etiology of, 205 
prognosis of, 206 
sequels of, 206 
symptoms of, 205 
treatment of, 207 
Dermatitis, differentiation of, from 

erysipelas, 107 
Dermatomyositis, 1238 
Dercum's disease, 938 
Dextrocardia, 432 
Diabete bronze, 702, 913 
Diabetes, coma from, 976 
decipiens, 908 
in gall-stones, 733 
insipidus, 919 

cerebral syphilis, 282 
diagnosis of, 920 
etiology of, 919 
prognosis of, 920 



Diabetes insipidus, symptoms of, 919 
treatment of, 920 
mellitus, 903 

cerebral syphilis, 282 
complications of, 910 
amaurosis, 911 
arteries, 912 
blood, 912 
coma, 910 
cystitis, 913 
dyspnoea, 910 
heart, 912 
gangrene. 914 

of lungs, 912 
genital, 913 
infectious, 914 
intestines, 913 
liver, 913 
mental, 910 
neuralgia, 911 
neuritis, 911 
pregnancy, 913 
renal, 913 
retinitis, 911 
skin, 914 
stomach, 913 
tuberculosis of lungs, 912 
course of, 914 
diagnosis of, 915 
etiology of, 904 
physiology of, 903 
prognosis of, 914 
symptoms of, glycosuria, 906 
tests for, 906 
polydipsia, 910 
polyphagia, 910 
urine, acetone, 909 
albuminuria, 908 
ammonium, 908 
beta-oxybutyric acid, 

908 
constituents, 908 
diacetic acid, 909 
pneumaturia, 910 
quantity, 906 
sugar, 906 
treatment of, complications, 918 
diet, 915 
general, 915, 917 
special, 916 
phosphatic, 807 
tuberculous, 311 
Diacetone, diabetic, 909 
Diamorrhysis, 961 

Diaphragmatic hernia, differentiation of, 
from pneumothorax, 566 
pleurisy, 553 
Diarrhoea, 648, 649, 684 

in cholera Asiatica, 209 
etiology of, 684, 689 
infantile, 658 

cholera infantum, 659 
chronic dyspepsia, 661 
etiology. 658 
iermental, 659 
ileocolitis, 060 



1290 



IXDEX 



Diarrhoea, infantile, treatment of acute 
colitis, 663 
dyspepsia, 662 
enteritis, 663 
of cholera infantum, 663 
of chronic dyspepsia, 663 
dietetic, 661 
modified feeding, 662 
in pneumonia, 146 
treatment of, 684 
in typhoid fever, treatment of, 52 
Diazo reaction, in malaria, 120 
in measles, 99 
in pneumonia, 147 
scarlatinal, 89 
in tuberculosis, 336 
in typhoid fever, 37 
Dicrotic pulse in typhoid fever, 24 
Dietl's crisis, 798 
Dietrich's heart stenosis, 405, 446 
Dilatation of aorta, intermittent, 482 
of bronchi. 502 
of heart, 434 

differentiation of, from peri- 
carditis, 385 
in typhoid fever, 25 
of mesenteric vessels, 691 
of oesophagus, 593 
of stomach, acute, 610 
chronic, 611 
Diphtheria, 159 

bacteriology of, 159 
complications of, 166 
alimentary, 169 
glands, 169 
heart, 168 
nephritis, 168 
paralysis, 166 
respiratory, 168 
skin, 169 
course of, 170 
diagnosis of, 169 
differentiation of, 170 

from scarlatina, 87, 92 
from tonsillitis, 585 
from Vincent's angina, 170 
dissemination of, 161 
etiology of, 159 

bacillus diphtherise, 159 
Klebs-Loeffler bacillus, 159 
localizations of. special, 164 
ear, 166 
eye, 166 
genitalia, 166 
larynx, 165 
hose, 164 
skin, 166 
prognosis of, 170 
sequelae of, 166 
symptoms of, 162 

classifications of, 162 
special, 164 
treatment of, 171 
general, 174 
local, 171 
prophylactic, 171 



Diphtheria, treatment of, serotherapy, 
172 
symptomatic, 174 
types of, 162 

catarrhal, 163 
chronic, 163 
general infection, 163 
latent, 163 
pharyngitic, 163 
septic, 164 
simple, 163 
tonsillitic, 163 
Diphtheritic croup, 165 
enteritis, 655 
ophthalmia, 166 
otitis, 166 
vulvo vaginitis, 166 
Diphtheroid, 159 
Diplegia, in cerebral infantile paralysis, 

996 
Diplococcus intra cellularis meningitidis, 

1043, 1045 
Diplopia, 1152 
Dipsomania, 1241 
Disinfection, by formaldehyde, 79 
Dislocation of kidney, 795 

of spine, 1070 
Disseminated encephalomyelitis, 1095 

sclerosis, 1103 
Distoma of kidney, 829 
of lung, 541 
pulmonale, 1275 
Distomiasis, 1275 
Dittrich's mycotic plugs, 499 
Diver's paralysis, 1085 
Drachontiasis, 1273 
Dracunculus medinensis, 1273 
Dropsy, cardiac, 422, 427 
Drug eruptions, differentiation of, from 
measles, 101 
rashes, differentiation of, from 
scarlatina, 92 
Drtisenfieber, 371 
Dubini's disease, 1216 
Duct, common, in gall-stones, 731 
cystic, in gall-stones, 731 
| Ductless glands, diseases of, 877' 
Ductus Botalli, patency, 431 
Duke's disease, 103 
Dunbar's serum, 487 
Duodenal ulcer, complications of, 657 
'etiology of, 655 
diagnosis of, 657 
differentiation of, from round 

ulcer, 624 
issues of, 657 
symptoms of, 656 
treatment of, 657 
Duroziez's murmur, 405 
Dvsacusis, 1164 
Dysarthria, 948, 958, 959 
Dysbasia intermittens, 468 
Dysentery, 224 

classification of, 225 
amoebic, 227 

complications of, 229 



INDEX 



1291 



Dysentery, amoebic, issues of, 229 
liver abscess in, 708 
pathology of, 229 
symptoms of, 228 
treatment of, 231 
indeterminate types, 230 
catarrhal, 230 
croupous, 231 
gangrenous, 231 
parasitic, 231 
Shiga's bacillary, 225 

complications of, 227 
diagnosis of, 227 
pathology of, 226 
prognosis of, 227 
symptoms of, 226 
treatment of, 231 
Dyspepsia, acute, 598 

in children, acute, 659 

chronic, 661 
intestinal, 648 
nervosa, 648 
Dysphagia in tuberculosis, 333 
Dyspnoea in heart disease, 420 

Kussmaul's, in diabetes, 910 
tuberculous, 315 



Ear, syphilis of, 290 

tuberculosis of, 354 
Ebstein's cure, 937 
Echinococcus disease, 1262 

of liver, differentiation of, from 
abscess, 724 
from biliary cirrhosis, 706, 
724 
multilocular, 716 
unilocular, 714 
of lungs, 540 
renal, 828 
. of thyroid gland, 887 
Eclampsia in contracted kidney, 782 

in kidney of pregnancy, 771- 
Eczema, differentiation of, from chicken- 
pox, 83 
from erysipelas, 107 
of tongue, 577 
Ehrlich's diazo reaction, 37 
Emaciation in tuberculosis, 334 
Embolism of aorta, 483 
of brain, 979 
cerebral, 979 
of kidneys, 792 
of lungs, 535 

in typhoid fever, 36 
of mesentery, 691 
of spinal cord, 1083 
of spleen, 882 

in valvular heart disease, 422 
Emphysema of lungs, 510 
Empyema, 551 

necessitatis, 552 
pulsans, 552 
pneumococcic, 147, 552 



Empyema, streptococcic, 551 

in typhoid fever, 36 
Encephalitis, 1011 

acute hemorrhagic, 1011 

ophthalmoplegic, 1011 
etiology of, 1010 
in influenza, 177 
pathology of, 1011 
poliencephalitis, 1012 
inferior, 1012 
superior, 1012 
poliencephalomyelitis, 1012 
prognosis of, 1012 
suppurative, 1013 
syphilitic, 285 
treatment of, 1013 
Encephalomalacia, atheromatous, 985 
embolic, 979 
syphilitic, 284 
Encephalomyelitis, disseminated, 1095 
Encephalopathia, saturnina, 1250 
Endarteritis deformans, 463 

syphilitic, 285 
Endiamorrhysis, 962 
Endocarditis, 392 
acute, 392 

benign, 397 

diagnosis of, 399 
etiology of, 397 
localization of, 398 
pathology of, 397 
prognosis of, 399 
symptoms of, 398 
treatment of, 399 
malignant, 392 

diagnosis of, 396 
etiology of, 392 
pathology of, 392 
prognosis of, 397 
symptoms of, 394, 395 
treatment of, 397 
types of, 394 

bacteriological, 396 
septic, 395 
typhoidal, 394 
visceral, 395 
verrucose, 397 
chorea, relations of, 1211, 1213 
chronic, 400 

etiology of, 400 
pathology of, 400 
symptoms of, 401 
differentiation of, from pericarditic 
rub, 384 
from typhoid fever, 44, 45 
rheumatic, 194 
scarlatinal, 88 
syphilitic, 277 
tuberculous, 334, 356 
in typhoid fever, 25 
ulcerative, pneumococcic. 14S 
Endocardium, diseases of, 892 
Endothelioma of spleen, 883 
Enemata, nutrient, 625 
English sweats, 372 
Enstrongylus of kidney, 820 



1292 



INDEX 



Enteralgia, 690 
Enteritis, actinomycotic, 258 
acute, 649 
diagnosis of, 650 
etiology of, 649 
pathology of, 649 
symptoms of, 649 
treatment of, 650 
chronic, 651 

pathology of, 651 
prognosis of, 653 
symptoms of, 652 
treatment of, 653 
croupous, 655 
differentiation of, from typhoid 

fever, 43 
diphtheritic, 655 
mucous, 654 
phlegmonous, 655 
Enterocolitis in children, 660 
Enterodynia, 690 
Enterokinase, 651 
Enteroliths, 674 
Enteroptosis, 680 
etiology of, 600 
symptoms of, 681 
treatment of, 681 
Enterospasm, 689 
Enterostenosis, 673 
Ephemeral fever, 371 
Epidemic cerebrospinal meningitis, 1045 
Epididymitis in mumps, 189 
Epilepsy, 1201 

in cerebral infantile paralysis, 995, 

998 
convulsions in cerebral syphilis, 284 
course of, 1207 
diagnosis of, 1205 
differentiation of, 1205, 1206 
etiology of, 1201 
Jacksonian, 944, 945, 1004, 1007 
differentiation of, 1205 

from organic disease, 1007 
pathology of, 1202 
prognosis of, 1207 
symptoms of, 1202 
treatment of, 1207 
types of, 1204 
Epileptiform attacks in paretic demen- 
tia, 1024 
Epistaxis, etiology of, 488 
in influenza, 178 
treatment of, 489 
in typhoid fever, 35 
Erb-Goldflam syndrome, 1032 
Erb's sign, 1219 
Ergotism, 1253 
Eructations, gastric, 644 
Erysipelas, 103 

bacteriology of, 104 
complications of, 105 
alimentary, 106 
circulatory, 106 
genito-urinary, 106 
nervous, 105 
respiratory, 106 



Erysipelas, complications of, septic, 107 
course of, 105 
as curative agent, 109 
diagnosis of, 107 
differentiation of, 107 
from angina, 107 
from cellulitis, 107 
from dermatitis, 107 
from eczema, 107 
from erysipeloid, 107 
from erythema, 107 
from lymphangitis, 107 
from malignant pustule, 107 
from phlegmon, 107 
etiology of, 104 

streptococcus erysipelatos, 104 
of larynx, 106 
of lungs, 106 
of pharynx, 106, 107 
prognosis of, 108 
recurrence of, 108 
symptoms of, 104 
chill, 104 
eruption, 104 
fever, 105 
incubation, 104 
treatment of, 108 
general, 109 
local, 108 
mechanical, 108 
medicinal, 109 
prophylaxis, 108 
serotherapy, 109 
varieties of, 108 
Erysipeloid, 107 

differentiation of, from erysipe- 
las, 107 
Erythema, differentiation of, from ery- 
sipelas, 107 
rheumatic, 192, 196 
visceral crises in, 867 
Erythromelalgia, 1235 
Exophthalmos, goitrous, 889 
Extradural abscess, differentiation of, 

from brain abscess, 1017 
Exudates, character of fluid, 761, 762 
Eye, syphilis of, 287 



Facial hemiatrophy, 1157 

hemihypertrophy, 1158 

paralysis, 1158 
Facies cholerica, 209 
Faeces, functional examination of, 652 
Fallopian tubes, syphilis of, 292 

tuberculosis of, 353 
Famine fever, 55, 61 
Farcy, 245 

Fasciola hepatica, 1276 
Fat necrosis, pancreatic, 743 

in urine, 806 
Fatty heart, 442 

liver, 717 



INDEX 



1293 



Fatty liver, differentiation of, from ab- 
scess, 724 
from portal cirrhosis, 701, 724 
Febricula, 371 
Febris recurrens, 61 
Fehleissen's streptococcus erysipelatos, 

103 
Felons, syringomyelic, 1111 
Fever-cake, in malaria, 119 
Fibrin casts in pneumonia, 142 
Filaria medinensis, 1273 

nocturna, 1272 
Fish poisoning, 1252 
Fissures of lungs, interlobar, 555 
Fistula in ano, 350 
Fistulae in gall-stones, 733 
Flint's murmur, 404, 412 
Floating liver, 719 

spleen, 884 
Fcetor ex ore, differentiation of, 530 
Folie cardiaque, 458 
Food poisoning, 1251 
Foot and mouth disease, 375 
Forced movements, 960 

postures, 960 
Formaldehyde as disinfectant, 79 
Forscheimer's spots, 102 
Fourth disease, Duke's, 103 
Fracture of spine, 1068 
Frantzel's rules, in valvular disease, 409 
Friction rub, pericarditic, 381, 382 

pleuritic, 545, 548 
Friedlander's bacillus, 137 
Friedreich's ataxia, 1135 

change of note, 326 

tones, 405 
Fumigation, formaldehyde, 79 
Funnel breast, 588 



Galactotoxismus, 1252 
Gall-bladder, cancer of, complications 
of, 742 
differentiation of, 742 
from gall-stones, 
734, 735 
etiology of, 741 
pathology of, 741 
symptoms of, 741 
diseases of, 725 

differential table, 735 
in gall-stones, 731 
inflammation of, 738 
sarcoma of, 741 
tumors of, 741 

differentiation of, from 

stones, 728 

chemistry of, 729 
complications of, ampulla 
Vateri, 732 
common duct, 731 
cystic duct, 731 
diabetes, 733 



Gall-stones, complications of, fistulse, 
733 
gall-bladder, 731 
intestinal obstruction, 732 
renal calculus, 733 
diagnosis of, 733, 734, 735 
differentiation of, from acute 
pancreatitis, 745 
from angioneurotic crisis, 

733 
from appendicitis, 733 
from cancer of gall-bladder, 

734, 735 
from cancer of pancreas, 

750 
from cholangitis, 734,735 
from cholecystitis, 734, 735 
from gastralgia, 733 
from gastric ulcer, 657, 733 
from lead colic, 733 
from mucous colic, 733 
from renal colic, 733 
from round ulcer of stom- 
ach, 624 
from syphilis, 733 
of liver, 275 
from tabes, 733 
etiology of, 728 
following typhoid fever, 31 
frequency of, 728, 729 
intestinal obstruction from, 

674, 676 
prognosis of, 736 
properties of, 729 
symptoms of, 730 
treatment of, colic, 736 
medicinal, 736 
prevention, 736 
surgical, 736 
varieties of, 729 
Gangrene, diabetic, 914, 918 
of lung, 528 

pneumonic, 149 
in tuberculosis, 333 
in typhoid fever, 36 
spontaneous symmetrical, 1235 
in typhoid fever, 24 
Gangrenous stomatitis, 576 
Gastralgia, 647 

differentiation of, 626 
from gall-stones, 733 
Gastrectasia, 610 
Gastric fever, 371 

ulcer, complications of, duodenal, 
655, 656, 657 
differentiation of, from duo- 
denal ulcer, 657 
from gall-stones, 733 
Gastritis, acute diphtheritic, 601 
parasitic, 601 
phlegmonous, 600 
simple, diagnosis of. 599 
etiology of. 598 
symptoms of, 598 
treatment ^t 599 
toxic, 600 



1294 



INDEX 



Gastritis, atrophic, 631, 633 
chronic, diagnosis of, 606 
etiology of, 601 
pathology of, 601 
symptoms of, 602 
treatment of, diet, 606 
lavage, 607 
medicinal, 608 
preventitive, 606 
differentiation of, from cancer, 626 
from gastralgia, 626 
from gastria ulcer, 626 
from hyperchlorhydria, 626 
from typhoid fever, 43 
pneumococcic, 149 
stenosing, 611 
Gastrodynia, 647 
Gastro-enterostomy in gastric cancer, 637 

in gastric ulcer, 629 
Gastroptosis, 680. See Enteroptosis. 
Gastrorrhagia, 637 
Gastrosuccorrhcea, diagnosis of, 643 
etiology of, 642 
prognosis of, 643 
symptoms of, 642 
treatment of, 643 
Gelatin injections, tetanus from, 248 
Genitalia, syphilis of, 290 
Genito-urinary tract, tuberculosis of, 350 
Genu valgum, rhachitic, 936 
Gerhardt's change of note, 326 
German measles, 102 

diagnosis of, 103 
differentiation of, 103 

from Duke's disease, 103 
from measles, 100 
from scarlatina, 100 
etiology of, 102 
prognosis of, 103 
symptoms of, 102 

constitutional, 103 
eruption, 102 
incubation, 102 
prodromes, 102 
stages, 102 
treatment of, 103 
Gersuny's sign, 686 
Gigantism, 900 
Gingivitis, scorbutic, 870 
Glanders, 244 

course of, 245 

diagnosis of, 247 

differentiation of, from anthrax, 241 

from smallpox, 76 
etiology of, 244 
pathology of, 245 
symptoms of, 245 
farcy, 245 

acute, 245 
chronic, 246 
glanders, 246 
acute, 246 
chronic, 246 
treatment of, 247 
Glandular fever, 371 
Glioma of brain, 1000 



Glissonlan cirrhosis of liver, 695 
Globulin, tests for, 801 
Globus, hystericus, 1187 
Glomerulo-nephritis, scarlatinal, 89 
Glossitis, acute, 578 . 

dessicans, 578 
Glottis, oedema of, 493 

in typhoid fever, 35 
spasm of, diagnosis of, 185 

differentiation of, from whoop- 
ing-cough, 185 
Glycosuria, 903, 906 
syphilitic, 277 
tests for, Fehling's, 906 
fermentation, 906 
phenylhvdrazin, 907 
Goitre, 886 

exophthalmic, 888, 890 
acute, 891 
course of, 891 
diagnosis of, 891 
etiology of, 888 
forme fruste, 891 
prognosis, 891 
symptoms of, 889 
accessory, 890 
cardinal, 889 
constitutional, 891 
tachycardia, 889 
treatment of, electrical, 892 
general, 891 
medicinal, 892 
organotherapy, 892 
thyroidectomy, 892 
Gonococcus. See Septic Affect ions, 130, 
133 
localizations, 260, 261 
Gonorrhceal infection, 260 
arthritis, 261 

classification, 262 
course, 262 
pathology, 262 
symptoms, 261 
treatment, 262 
variations, 262 
gonococcus, 260 
in blood, 260 
in brain and cord, 261 
in endocarditis, 261 
in joints, 260 
in liver, 260 
in myocardium, 260 
in pleura, 260 
in skin, 260 
in vessels, 261 
regional, 260 
septicopvaemia, 260 
Gout, 920 

complications of, 923 
diagnosis of, 924 
etiology of, 920 
pathology of, 922 
prognosis of, 924 
symptoms of, acute, 921 

chronic, 922 
treatment of, acute, 924 



INDEX 



1295 



Gout, treatment of, acute, alkalies, 925 

colchicum, 924 

diet, 925 

salicylates, 924 
chronic, 926 
Grafe's, von, sign, 890 
Grain poisoning, 1253 
Graphospasms, 1221 
Graves' disease, 888 
Greene's sign in pleurisy, 545 
Grindeiia, 509, 510 
Grippe. See Influenza, 175 
Grocco's sign in pleurisy, 547 
Guinea-worm disease, 1273 
Gumma. See Syphilis. 
Gums, tuberculosis of, 346 
Gutta cadens, 566 



H 



Habitus enteroptoticus, 680 
Haematemesis, diagnosis of, 629, 636 

differentiation of, haemoptysis, 538 

etiology of, 637 

in gastric cancer, 634, 632, 626 
ulcer, 620, 626 

in portal cirrhosis, 699 

symptoms of, 638 

syphilitic, 272 

treatment of, 628 

in typhoid fever, 30 
Haematomyelia, 1083 
Haematoporphyrinuria, 809 
Haematorrhachis, 1077 
Haematuria, 802 

angioneurotic, 802 

diagnosis of, 803 

endemic, 1275 

etiology of, 802 

renal colic causing, 819, 821 
tumor causing, 823 

symptoms of, 803 

treatment of, 804 
Hsemochromatosis, 702 

etiology, 746 ' 
Haemoglobinuria, 804 

epidemic, 804, 869 

etiology of, 804 

in malaria, 125 

nephritis in, 771 

paroxysmal, 804 

symptoms of, 804 

syphilitic, 276 

treatment of, 805 
Haemopericardium, 391 

differentiation of, from pericarditis, 
385 
Haemophilia, 873 

diagnosis of, 875 

etiology of, 874 

prognosis of, 875 

renal, 874 

symptoms of, 874 

treatment of, 875 
Haemoptoe, 537 



Haemoptysis, 320 

bronchiectasis causing, 503 
cause of tuberculosis, 321 
endemic, 1275 
forms of, 320, 321 
frequency of, 320 
in heart disease, 419 
of lungs, 537 

result of tuberculosis, 320 
symptoms of, 321 
in tuberculosis, 320 
Haemorrhoids, 683 
Haemothorax, 568 
"Half-moon" space, 547 
Hanford's tender toes in typhoid fever, 29 
Hanot's disease, 704 
Hay fever, 486 

etiology of, 486 
symptoms of, 486 
treatment of, 487 
Haygarth's nodosities, 928 
Head, actinomycosis of, 257 
Headache, in brain tumor, 1002, 1007, 
1008 
differentiation of, 1228 
fevers, treatment of, 54, 80 
in malaria, 121 
migraine, 1227 
sick, 1226, 1228 
in typhoid fever, 27 
Head's maximal points, 1230, 1232 
Hearing, centre for, 947 
Heart, See also Myocardium 
aneurysm of, 446 
arteriosclerosis of, 468 
atrophy of, 441 
block, 457 
dilatation of, 434 

diagnosis of, 436 
differentiation of, 436 

from encapsulated pleu- 
risy, 437 
from mediastinal obesity, 

437 
from pericarditis, 385 
from pulmonary consoli- 
dation, 436 
etiology of, 434 
pathology of, 434 
prognosis of, 437 
signs of auricular dilatation, 436 
of left ventricle dilatation, 

435 
of right ventricle dilata- 
tion, 436 
symptoms of, 435 
treatment of, 437 
in typhoid fever, 25 
disease cells, 420 
congenital, 430 

aortic atresia, 432 
dextrocardia, 432 
interauricular defects. 430 
interventricular defec t s . 

431 
patent ductus Botalli. 431 



1296 



IXDEX 



Heart disease, congenital, persistent 
isthmus aortse, 431 
prognosis of, 433 
pulmonary stenosis, 430 
symptoms of, general, 433 
transposition of vessels, 

432 
treatment of, 433 
tricuspid stenosis, 432 
valvular anomalies, 432 
valvular combined lesions, 417 
diagnosis of, 417 j 
prognosis of, 418 
course of, 422 
prognosis of, 422 
signs of. See Individual 

Lesions, 
symptoms of, 418 
cardiac, 418 
constitutional, 418 
embolism, 422 
gastro-intestinal, 420 
joint, 422 
kidney, 421 
liver, 421 
nervous, 419 
oedema, 422 
respiratory, 419 
spleen, 421 
treatment of, 423 

compensated lesions, 

42"3 
digitalis, 425 
exercise, 424 
hygiene, 423 
Oertel method, 425 
purgative, 425 
rest. 424 

Schott method, 425 
symptomatic, 427 
uncompensated les- 
ions, 424 
venesection, 425 
fatty, 442 

Adams-Stokes syndrome of, 443 
diagnosis of, 443 
etiology of, 442 
pathology of, 442 
prognosis of, 443 
signs of, 443 
symptoms of, 443 
treatment of, 444 
hypertrophy of, 438 
diagnosis of, 441 
etiology of, 439 
in interstitial nephritis, 780 
pathology of, 438 
prognosis of, 441 
signs of left ventricle hyper- 
trophy, 440 
of right ventricle hyper- 
trophy, 440 
symptoms of, 440 
treatment of, 441 
intermittence of, 458 
irritable, 439 



Heart murmurs, ansemic diastolic, 405 
systolic, 409, 414 
functional, 833 
diastolic, 405 
neuroses of, 451 
operations on, 450 
palpitation of, 451 
diagnosis of, 453 
etiology of, 452 
prognosis of, 453 
signs of, 452 
symptoms of, 452 
treatment of, 453 
pang, 458 

retraction of apex of, 388 
rupture of, 446, 450 
diagnosis of, 450 
etiology of, 450 
pathology of, 450 
symptoms of, 450 
treatment of, 450 . 
syphilis of, 277 
thrombosis of, 451 
tuberculosis of, 356 
Heat exhaustion, 1254 
Heberden's nodes, 929 
Hemiangesthesia, hysterical, 1184 
lesions in, crus, 957 

internal capsule, 953 
optic thalamus, 955 
pons, 958 
Hemianopsia, 946, 952. 954, 1147, 1148 
Hemiatrophy, facial, 1157 
Hemicrania, 1226 
Hemifacial atrophy, 1157 

hypertrophy, 1158 
Hemihvpertrophv, facial, 1158 
Hemiopia, 946, 952, 954 
Hemiplegia, in aged, 987 
alternating, 956, 957 
in apoplexy, 970, 972, 976, 988 
cerebral, 953 

embolism, 983, 988 
infantile paralysis, 994 
thrombosis, 986, 988 
collateral, 971 
cortical, 943 
double, 958 
etiology of, 976 
hysterical, 1187 
internal capsule lesion in, 953 
in pachymeningitis, 1039 
in pneumonia, 147 
spinal, 1086 
uraemic, 782 
Hemorrhage from bowels, in typhoid 
fever, 33 
of brain, 449, 965 

in syphilis, 285 
in cirrhosis of liver, 699 
mediastinal, 571 
of mesentery, 691 
of new-born, syphilitic, 297 
occult, 620, 638 
of oesophagus, 597 
from pancreas, 747 



INDEX 



1297 



Hemorrhage of spinal cord, 1083 
of thymus gland, 897 
in tuberculosis, 316 
in whooping-cough, 184 
in yellow fever, 217 
Hemorrhagic diseases, 866 

classification of, 866 
haemophilia, 873 
infantile scurvy, 872 
of new-born, 869 
purpura, 866 
scurvy, 870 
encephalitis, acute, 1011 
erosions of stomach, 624 
pachymeningitis, 1040 
pleurisy, 553 
Henoch's purpura, 868 
Hepar adiposum, 717 
migrans, 719 
mobile, 719 
Hepatargia, 699, 693, 727 
Hepatic fever, intermittent, 732 
insufficiency, 727 
vein cirrhosis of liver, 695 
vessels, diseases of, 723 
Hernia, diaphragmatic, 672 

differentiation of, from pneumo- 
thorax, 566 
external, 671 
internal, 671 
of linea alba, 624 
Herpes in malaria, 119 
in pneumonia, 146 
in tuberculosis, 317 
in typhoid fever, 24 
zoster, 1232 
Herpetic fever, 371 
Hiccough, 1175 
Hippocratic fingers, 336 

succussion, 566 
Hirschsprung's disease, 682 
His' bundle, 457 
Hodgkin's disease, 860 
Horse-shoe kidney, 795 
Hour-glass stomach, 616 
Hunger, disturbance of, sense of, 647 
Huntingdon's chorea, 1215 
Hutchinson's mask, 1117 
teeth, 297 
triad, 287 
Hydatids, 1262 

cysts. See Liver, Cysts of. 
Hydrarthrosis, intermittens, 1237 
Hydrencephalic state, 660 
Hydrencephaloid, 962 
Hydrobilirubin, test for, in stools, 653 
Hydrocephalus, acute, 1034 
chronic, acquired, 1036 

diagnosis of, 1036 
etiology of, 1036 
symptoms of, 1036 
treatment of, 1037 
congenital, 1034 
course of, 1036 
etiology of, 1034 
pathology of, 1035 

82 



Hydrocephalus, chronic, congenital, 

symptoms of, 1035 
Hydrochinon in urine, 809 
Hydrochloric acid, action of, 607 

tests for, in stomach, 603, 604 
Hydromyelus, 1109 
Hydronephrosis, 814 

diagnosis of, 815 

differentiation of, from cystic 
kidney, 828 
from ovarian tumor, 816 
from pyonephrosis, 815 

prognosis of, 816 

symptoms of, 814 

treatment of, 816 
Hydropericardium, 391 

differentiation of, from pericar- 
ditis, 384 
Hydroperitoneum, 759 
Hydrophobia, 252 

course of, 254 

diagnosis of, 255 

differentiation of, 255 

etiology of, 253 

incubation in, 253 

pathology of, 254 

prognosis of, 254, 255 

stages of, 253 

symptoms of, 253 

treatment of, 255 
inoculation, 255 
late, 256 

primary wound, 255 
prophylactic, 255 $ 
Hydrops articulorum intermittens, 1237 

pericardii, 391 

renum cysticus, 826 
Hydrorrhachis interna, 1109 
Hydrotherapy, in pneumonia, 158 

in typhoid fever, 49 
Hydrothorax, 567 

diagnosis of, 568 

differentiation of, from pleurisy, 558 

etiology of, 567 

symptoms of, 568 
Hyperaciditas hydrochlorica, 640 
Hyperacusis, 1164 
Hypersemia of brain, 962 

of spinal cord, 1083 
Hyperesthesia of stomach, 646 
Hyperchlorhydria, diagnosis of, 641 

differentiation of, 626, 641 

etiology of, 640 

in gastric ulcer, 621 

prognosis of, 641 

symptoms of, 640 

treatment of, 627, 641 
Hyperdiamorrhysis, 962 
Hyperkinesis cordis, 451 

gastric, 644 
Hypernephroma, 825 
Hyperorexia, 648 
Hyperosmia, 1146 
Hyperostosis cranii, 900 
Hypersecretion, 578 

gastric, 642 



1298 



INDEX 



Hypertrophy of brain, 1028 
of heart, 438 

arteriosclerotic, 467 
hemifacial, 1158 
of lungs, 514 
of pylorus, 636 
of thymus gland, 897 
of thyroid gland, 886, 888 
Hypochlorhydria, 644 
Hypochondriasis, 1197 
Hypodermatoclysis, 212 
Hypophysis, diseases of, 898 
Hyposecretion, gastric, 644 
Hypostasis of lungs, 534 

in typhoid fever, 36 
Hysteria, 1184 

angina pectoris, 461 
course of, 1191 
diagnosis of, 1191 

differentiation of, from hydro- 
phobia, 255 
from multiple sclerosis, 1108 
from myelitis, 1094 
from serous meningitis, 1055 
from tetanus, 250 
from whooping-cough, 185 
etiology of, 1184 
ileus in, 675 
prognosis of, 1191 
stigmata, 1184 

hemianaesthesia, 1184 
sensory, 1184 
symptoms of, 1184 
treatment of, 1191 
Icing liver, 758 
Icterus, 725 

acute catarrhal, etiology of, 739 
prognosis of, 740 
symptoms of, 740 
treatment of, 740 
febrile, 372 
in cancer of liver, 712 
in cirrhosis of liver, 700 
diagnosis of, 728 

differentiation of, from biliary cir- 
rhosis of liver, 706 
epidemic, 373 
etiology of, 725 
gravis, 694 
haematogenous, 725 
in heart disease, 421 
neonatorum, 725 
pneumonic, 149 
prognosis of, 728 
symptoms of, 726 
syphilitic, 275 
treatment of, 728, 740 
in typhoid fever, 30 
urobilin, 725, 726 
Ichthyosis of tongue, 577 
Ichthyotoxismus, 1252 
Idiocy, amaurotic family, 1137 
Ileocolitis in children, acute, 660 

dysenteric, 660 
Ileus, dynamic, 675 
hysterical, 675 



Incoordination. See Ataxia 
Indicanuria, 808 
Indurative pneumonia, 520 
Infantile convulsions, 1209 
diarrhoea, 658 
paralysis, cerebral, 994 

diplegic form, 996 
hemiplegic form, 995 
Infantilism, 894 
Infarcts of kidney, 792, 818 

of lungs, 535 
Inflammation of brain, 1010 
of bronchi, 495 
of meninges, 1041 
of mesentery, 690 
of pancreas, acute, 743 

chronic, 746 
of spinal cord, 1089 
of thyroid gland, 887 
Influenza, 175 

bacteriology of, 176 
diagnosis of, 181 
differentiation of, 181 
from bronchitis, 181 
from coryza, 181 
from dengue, 207 
from measles, 101, 181 
from meningitis, 181 
from miliary tuberculosis, 181 
from typhoid fever, 181 
etiology of, 176 
prognosis of, 181 
symptoms of, 176 
alimentary, 180 
circulatory, 180 
classification of, 176 
duration of, 176 
fever, 177 
genito-urinary, 180 
joint, 180 
muscle, 180 
nervous, 177 
respiratory, 178 
skin, 180 
types of, 176 
treatment of, 181 

catarrhal symptoms, 182 
convalescence, 182 
heart symptoms, 182 
nervous symptoms, 182 
varieties of, 175 
Infusions, saline, 158 
Insane, paralysis of, 1020 
Insolation, 1254 
Insular sclerosis, 1103 
Interlobar pleurisy, 554 
Intermittent limping, 468 
Internal capsule, localizing symptoms, 

951 
Interstitial nephritis, chronic, 777 
Intestinal dyspepsia, 648 
obstruction, 670 
stenosis, complications of, 611 
Intestines, amyloidosis of, 272 
anthrax of, 242 
arteriosclerosis of, 469 



INDEX 



1299 



Intestines, cancer of, 670 

complications of, 679 
diagnosis of, 679 
differentiation of, 679 
etiology of, 677 
pathology of, 677 
symptoms of, 678 
treatment of, 679 
diseases of, 648 

foreign bodies in, forms of, 674 
hemorrhage of, 682 
diagnosis of, 683 
etiology of, 682 
symptoms of, 682 
treatment of, 683 
obstruction of, diagnosis of, 675 

differentiation of, from acute 

pancreatitis, 745 
foreign bodies, 674 
gall-stones causing, 732 
intussusception, 670 
invagination, 670 
knots, 672 
strangulation, 671 
stricture, 673 
treatment of, medical, 676 

surgical, 677 
tumors, 674 
twists, 672 
volvulus, 672 
syphilis of, 272 
typhoid fever, hemorrhage from, 33 

perforation of, 34 
tuberculosis of, 347, 349 
tumors of, benign, 680 
cancer of, 677 
sarcoma of, 680 
ulceration of, 655, 657 
syphilitic, 272 
in tuberculosis, 335 
ursemic, 783 
Intoxications, 1241 
Intracranial aneurysm, 989 
Intubation in diphtheria, 175 
Intussusception of bowel, 670 
etiology of, 670 
issues of, 671 
pathology of, 670 
varieties of, 670 
Iridoplegia, 1151 
Iritis, syphilitic, 288 
Ischialgia, 1181 
Isthmus aortse, persistent, 431 
Itching, treatment of, 740 



Jaboulay's sign, in hour-glass stomach, 

617 
Jacksonian convulsions, 1004, 1007 
epilepsy, causes of, 944 

characteristics of, 945 
differentiation of, 1205 
Jaundice. See Icterus, 725 
acute catarrhal, 739 



Jaundice, acute febrile, 372 

epidemic, 373 
Joffroy's sign, 890 
Joints, rheumatic, 192 

syphilis of, 293 

tuberculosis of, 357 
Jungle fever, 125 

pernicious malaria, 125 
Justus test, in syphilis, 268 



K 



Kahler's disease, 801 

Kakke, 236 

Keratitis, syphilitic, 287 

Keratosis of tongue, 577 

Kernig's sign, 1054 

Kidney, anomalies of, 794, 799 

Kidneys, absent, 794 

amyloid degeneration of, 793 

differentiation from acute 
nephritis, 796, 797 
from chronic nephritis, 

796, 797 
from congested kid- 
ney, 796, 797 
etiologv of, 793 
pathology of, 793 
symptoms of, 793 
syphilitic, 276 
anomalies of secretion, 799 

of structure, 794 
arteriosclerosis of, 468 
ascending infection of, 778 
calculus of, 817 
cancer of. See Renal Cancer 
congestion of, passive, 791 
diagnosis of, 792 
differentiation of, 796, 797 
etiology of, 791 
pathology of, 791 
symptoms of, 792 
contracted, arteriosclerotic, 778, 784 
embolic, 778 
primary, 778 
secondary, 775 
cystic, 826 

diagnosis of, 828 
etiology of, 826 
pathogenesis of, 827 
pathology of, 827 
symptoms of, 827 
treatment of, 828 
degeneration of, cystic, 826 
diseases of, 767 
dislocation of, acquired, 795 

congenital, 795 
distoma of, 829 
echinococcus of. See Renal Echino- 

coccus 
embolism of, 792 
enstrongylus of, 829 
floating, 795 
horse-shoe, 795 
infarction of, 792 



1300 



INDEX 



Kidneys, infarction of, pigment, 818 
uric, 818 
large, red, 775 

variegated, 775 
white, 774 
malformations of, 794 
movable, 795 

complications of, 798 
diagnosis of, 799 
etiology of, 795 
prognosis of, 799 
symptoms of, 795 
treatment of, 799 
of pregnancy, eclampsia in, 771 
rudimentary, 794 
sarcoma of, 825 
stone of, 817 
supernumerary, 794 
syphilis of, 277 
tuberculosis of, 351 
Klebs-Loeffler bacillus, 159 
Kopftetanus, 250 
Koplik's spots, 97 
Kreatotoxismus, 1251 
KussmauPs breathing, 910 
Kyphosis, rhachitic, 933 



Labioglossopharyngeal paralysis, 

1029 
Lactosuria, 905 

Lachrymal glands, symmetrical hyper- 
trophy of, 580 
Lactic acid in gastric cancer, 633 
etiology of, 634 
tests for, 634 
in infantile dyspepsia, 663 
Lacunar degenerations of brain, 987 
Laennec's cirrhosis of liver, 695 
La Grippe, 175. See Influenza 
Landry's paralysis, 1102 
etiology of, 1102 
pathology of, 1102 
prognosis of, 1103 
symptoms of, 1103 
Langerhans' islands, 746, 904 

insufficiency, 904 
Laryngeal gumma, 279 
perichondritis, 279 

in typhoid fever, 35 
stenosis, 279 

ulcers, in typhoid fever, 35 
Laryngismus stridulus, 1169 
Laryngitis, acute catarrhal, 489 
diagnosis of, 490 
etiology of, 489 
symptoms of, 490 
treatment of, 490 
in children, 491 
fibrinous, 491 
nodose, 491 
submucous, 491 
suppurative, 491 
chronic catarrhal, 492 



Laryngitis, chronic catarrhal, etiology 
of, 492 
symptoms of, 492 
treatment of, 492 
hypertrophic, 492 
pachydermia, 492 
tuberosa, 492 
diphtheritic, 165 
in influenza, 178 
rheumatic, 192, 197 
stridulous, 491 
syphilitic, 279 
Larynx, diseases of, 489 

differentiation of, from whoop- 
ing-cough, 185 
erysipelas of, 106 
oedema of, 493 

paralysis of, 1168, 1169, 1170 
perichondritis of, 493 
symptoms of, 494 
treatment of, 494 
syphilis of, 279 
tuberculosis of, 354 
tumors of, 494 
ulcerations of, 494 
Lasegue's sign, 193, 1182 
Lathyrism, 1254 

Lead colic, differentiation of, from gall- 
stones, 733 
poisoning, acute, 1248 
chronic, 1248 
Leontiasis ossea, 900 
Leprosy, 366 

bacteriology of, 367 
course of, 370 
diagnosis of, 370 

differentiation of, from syringo- 
myelia, 1112 
distribution of, 366 
pathology of, 368 
prognosis of, 370 
symptoms of, 368 
treatment of, 370 
Leptomeningitis, 1041 
chronic, 1056 
spinal, 1078 
Leukaemia, 850 

classification of, 850 
lymphatic, acute, 850 

diagnosis of, 852 
symptoms of, 851 
chronic, 852 

course of, 853 
diagnosis of, 854 
etiology of, 852 
symptoms, 852 
myeloid, 854, 857 

complications of, 857 
diagnosis of, 857 
differentiation of, 858 
prognosis of, 859 
symptoms of, 854 
treatment of, 859 
Leukansemia, 858 
Leukocythsemia, 850 
Leukocytosis in pneumonia, 146 



INDEX 



1301 



Leukopenia in typhoid fever, 26 
Leukoplakia, syphilitic, 271 

of tongue, 577 
Leyden-Curschmann spirals, 508 
Lichen scrofulosorum, 358 
Lien mobile, 884 
Lientery, 650 

Life assurance, syphilis and, 295 
Lingual tonsil, 587 
Lips, tuberculosis of, 346 
Lipuria, 806 
Lithiasis, 747 

diagnosis of, 747 
symptoms of, 747 
Lithuria, 807 

Litten's diaphragmatic sign in pneu- 
monia, 143 
sign in tuberculosis, 324 
Little's disease, 997 
Liver, abscess of, 707 
amoebic, 708 

diagnosis of, 710 
differentiation of, 710, 724 
from gall-stones, 710 
from sepsis, 44 
from subphrenic ab- 
scess, 710 
from typhoid fever, 44 
pathology of, 708 
symptoms of, hepatic, 709 
icterus, 710 
rupture, 710 
septic, 709 
treatment of, 711 
cholangitic, 708 

differentiation of, from cancer, 
713, 724 
from cirrhosis, 724 
from echinococcus, 724 
from fatty liver, 724 
from pleurisy, 559 
from stasis, 724 
from syphilis, 724 
from tumors, 724 
etiology of, 707 
pylephlebitic, 707 
septic, 707 
solitary, 708 
tropical, 708 
in typhoid fever, 31 
varieties of, 707 
actinomycosis of, 258 
amyloid, 275, 717 
diagnosis, 718 

differentiation of, from cancer, 
713, 724 
from portal cirrhosis, 701, 
724 
etiology of, 717 
pathology of, 718 
symptoms of, 718 
anomalies of, 719 
atrophy of, acute yellow, 692 
course of, 694 
diagnosis of, 694, 724 
differentiation of, 694 



Liver, atrophy of, acute yellow, etiology 
of, 692 
symptoms of, 693 
treatment of, 695 
cancer of, 711 

diagnosis of, 713 
differentiation of, 713, 724 
from abscess, 713, 724 
from amyloid, 713, 724 
from biliary cirrhosis, 706, 

724 
from corset liver, 713 
from hydatid, 713, 724 
from portal cirrhosis, 701, 

702, 724 
from renal tumors, 714 
from stasis, 713, 724 
from syphilis, 275, 713, 724 
primary, 711 
secondary, 711 
symptoms of, ascites, 712 
cachexia, 712 
icterus, 712 
liver, 712 
treatment, 714 
cirrhosis of, 273, 695 
alcoholic, 695 
atrophic, 695 
biliary, 695, 704 

diagnosis of, 705 
differentiation of, 705, 724 
from cancer, 706, 724 
from echinococcus, 

706, 724 
from icterus, 706 
from portal cirrhosis, 
705, 724 
etiology of, 704 
symptoms of, 704 
digestive, 705 
icterus, 704 
liver, 704, 705, 706 
nutrition, 705 
spleen, 705 
urine, 705 
treatment of, 706 
capsular, 695 
cardio tuberculosa, 336 
Glissonian, 695 
Hanot's, 695, 704 
hepatic vein, 695 
in heart disease, 421 
Laennec's, 695 
malarial, 120 
mixed, 695 
pigmentary, 702 

differentiation of, from 
portal, 702 
portal, 695 

classification of, 695 
complication of, 699 
cardiac, 700 
febrile. 700 
hsematemesis, 099 
hemorrhages, 009 



1302 



INDEX 



Liver, portal cirrhosis, complication of, 
icterus, 700 
nephritis, 700 
peritonitis, 700 
pulmonary, 700 
course of, 701 
diagnosis of, 701 
differentiation of, 701, 724 
from abscess, 724 
from amyloid, 701, 724 
from Banti's disease, 

702 _ 
from biliary cirrhosis, 

705, 724 
from cancer, 701, 702, 

724 
from chronic peritoni- 
tis, 702, 764 
from fatty, 701, 724 
from hydatid cyst, 

724 
from icterus, 701, 724 
from . perihepatitis, 

702, 764 
from pigmentary cirr- 
hosis, 702 
from pseudocirrhosis 

pericarditica, 702 
from pylethrombosis, 

702 
from stasis, 701, 702, 

724 
from syphilis, 701, 
702, 724 
etiology of, 696 
pathology of, 696, 705 
prognosis of, 701 
symptoms of, 697 
clinical, 697 
general, 699 
liver, 697 
treatment of, medical, 703 
surgical, 703 
tuberculous, 311 
congestion of, arterial, 720 
passive, 421, 721 

differentiation of, 722, 724 
etiology of, 721 
pathology of, 721 
symptoms of, 721 
corset, 720 
cysts of, echinococcus, 714 

complications of, 715 
diagnosis of, 715 
differentiation of, 715, 724 
multilocular, 716 
prognosis of, 716 
rupture of, 715 
symptoms of, 714 
treatment of, 716 
unilocular, 714 
hydatid, differentiation of, from 

portal cirrhosis, 724 
non-parasitic, 715 
diseases of, 692 

differential table of, 724 



Liver, enlargement of, differentiation of, 
from pleurisy, 559 
fatty, 717 

differentiation of, from abscess, 
724 
from portal cirrhosis, 701, 
724 
etiology of, 717 
pathology of, 717 
symptoms of, 717 
floating, 719 
flukes, 1276 
gumma of, 274 
large, causes of, 702 
lob'ulated, 274 

nut-meg, in heart disease, 421 
perihepatitis, 273 
sarcoma of, 711 
small, causes of, 701 
syphilis of, 273 

differentiation of, from abscess, 
724 
from cancer, 713, 724 
from portal cirrhosis, 701, 
702, 724 
tuberculosis of, 347, 336, 350 
tumors of, differentiation of, from 

abscess, 724 
wandering, 719 
Lock-jaw, 247 
Locomotor ataxia, 1113 
Lceffler's solution, 172 
Ludwig's angina, 580 
: Lues venerea, 262 
Lumbago, 1239 
Lumbar puncture, 1052 
Lumpy-jaw, 257 
Lungs, abscess of, 526 

bacteriology of, 526 
diagnosis of, 527 
differentiation of, 527 

from gangrene, 530 
etiology of, 526 
pathology of, 526 
. pneumonic, 149 
prognosis of, 527 
symptoms of, 526 
treatment of, 527 
in typhoid fever, 36 
actinomycosis of, 259 
anthracosis of, 522 
anthrax of, 243 
arteriosclerosis of, 469 
atelectasis of, 524 
acquired, 525 

etiology of, 525 
pathology of, 525 
symptoms of, 525 
treatment of, 525 
congenital, 524 

etiology of, 524 
pathology of, 524 
symptoms of, 524 
treatment of, 524 
calculi of, 320 



INDEX 



1303 



from pleurisy, 559 
from pneumothorax, 566 

signs of, 326 
chalicosis of, 523 
circulatory affections of, 534 
cirrhosis of, 520 
congestion of, acute, 53-4 

passive, 534 

treatment of, 535 

in typhoid fever, 36 
diseases of, 510 
embolism of, 535 

diagnosis of, 536 

etiology of, 535 

pathology of, 535 

symptoms of, 535 

in typhoid fever, 36 
emphysema of, 510 

diagnosis of, 513 

differentiation of, 513 

etiology of, 511 

interstitial, 513 

pathogenesis of, 511 

pathology of, 511 

prognosis of, 514 

symptoms of, 513 

treatment of, 514 
erysipelas of, 106 
fever, 136 
flukes, 1275 
gangrene' of, bacteriology of, 528 

complications of, 530 

course of, 530 

diagnosis of, 530 

differentiation of, 530 

etiology of, 528 

pathology of, 528 

physical signs of, 530 

pneumonic, 149 

prognosis of, 530 

symptoms of, 530 

treatment of, 531 

in tuberculosis, 333 

in typhoid fever, 36 
haemoptysis, 537 

complications of, 538 

course of, 539 

diagnosis of, 538 

etiology of, 537 

prognosis of, 539 

symptoms of, 538 

treatment of, 539 
hypertrophy of, 514 

differentiation of, from emphy- 
sema, 514 
hypostasis of, 534 
induration of, pneumonic, 149 
infarct of, 535 

diagnosis of, 536 

etiology of, 535 

pathology of, 535 

symptoms of, 535 
interlobar fissures of, 555 
oedema of, 536 

etiology of, 536 



Lungs, oedema of, in heart disease, 420 
pathology of, 536 
in rheumatism, 197 
symptoms of, 536 
treatment of, 537 
parasites of, 540 
distoma, 541 
echinococcus, 540 
diagnosis of, 541 
prognosis of, 541 
symptoms of, 540 
treatment of, 541 
senile, 513 
siderosis of, 523 
stones, 320, 506 
syphilis of, 280 
tuberculosis of, 318 
tumors of, 531 
benign, 533 
cancer, 531 

etiology of, 531 
symptoms of, 532 

complications, 533 
compression, 532 
general, 532 
metastasis, 532 
physical signs, 532 
sputum, 532 
differentiation of, from pneu- 
monia, 153 
lymphosarcoma, 533 
sarcoma, 533 
Lupus, 358 

Lymph glands, tuberculosis of, 337 
Lymphaemia, acute, 850 

chronic, 852 
Lymphangitis, differentiation of, from 

erysipelas, 107 
Lymphatism, 886 
Lymphoma, malignant, 860 
Lymphosarcomatosis, differentiation of, 

864 
Lyssa, 252 
Lyssophobia, 255 



M 



Maculae tendineae, 379 
Maidism, 1253 
Maladie de Roger, 431 

de Woillez, 534 
Malaria, 109 

cachexia of, 122 
chronic, 122 
diagnosis of, 125 
differentiation of, 126 

from other febrile diseases, 127 
from sepsis, 126 
from typhoid fever, 44, 45 
etiology of, 109 

Plasmodium, 110 

forms of. sestivo-autum- 
nal, 112 
half-moons. 112 
quartan. 110 



1304 



IXDEX 



Malaria, plasmodium of, forms of, tertian, 
111 
pernicious, 122 

etiology of, 122 
forms of, 124 
algid, 125 
alimentary, 125 
biliary, 125 
cerebral, 124 
comatose, 124 
convulsive, 125 
hsemoglobinuric, 125 
hemorrhagic, 125 
meningeal, 124 
typhoid, 123 
prognosis of. 127 
relapses of. 122 

relation of, to other diseases, 122 
spontaneous recovery from, 127 
symptoms of, 115 
articular, 121 
blood, 118 
circulatory, 119 
digestive, *120 
fever, 115 

aestivo-autuninal^ 117 
intermittent, 117 
quartan, 115 
tertian, 116 
genito-urinary, 120 
muscular, 121 
nervous. 121 
respiratory, 119 
skin, 119 

special senses, 121 
spleen. 118 
treatment of. 127 

prophylaxic, 127 
specific, 127 
symptomatic, 128 
Mai perforant du pied, 1120 
Mallein. 245 
Malta fever, 233 

complications of, 234 
course of, 235 
diagnosis of. 235 
etiology of. 233 
prognosis of. 235 
symptoms of, 234 
treatment of. 235 
types of, 235 
Mamma, syphilis of, 294 
tuberculosis of, 353 
Mania a potu, 1244 
Marriage after syphilis. 299 
Mastitis, svphilitic, 294 
Measles, 96 

clinical course of, 96 
diagnosis of, 101 
differentiation of, 100 

from drug eruptions, 101 
from German measles, 100 
from influenza, 101, 181 
from scarlatina, 100 
from sepsis, 101 
from smallpox, 67, 75 



Measles, differentiation of, from typhus 
fever, 60, 101 
from variola, 101 
etiology of, 96 

German. See German Measles 
prognosis of, 101 
stages of, 96 
symptoms of, 96 
cardiac, 99 
digestive, 99 
eruption, 97 
fever, 98 

general course, 96 
genito-urinary, 99 
glandular, 99 
nervous, 99 
respiratory, 98 
splenic, 99 
treatment of, 101 

of complications, 102 
hygienic, 101 
prophylactic, 101 
Meat poisoning, 1251 
Mediastinal hemorrhage, 571 
pleurisy, 554 
tumors, 569 

diagnosis of, 570 
symptoms of, 569 
treatment of, 571 
Mediastinitis, acute, 571 

chronic, 571 
Mediastino-pericarditis, 387 
Mediastinum, diseases of, 569 
Megalogastria, 614 
Megalomania, 1022 
Melanaemia, in malaria, 118 
Melanoderma, 877, 879 
Melanoglossia, 578 
Melanotrichia linguae, 578 
Melanuria, 713 
Melasma suprarenale, 877 
Meniere's disease, diagnosis of, 1166 
etiology of, 1165 
symptoms of, 1165 
treatment of, 1166 
Meninges, cerebral, diseases of, 1037 
hemorrhage into, 1040 
inflammation of, 1041 
spinal, diseases of, 1076 

hemorrhage, 1076 
hyperaemia, 1076 
leptomeningitis, 1077 
pachymeningitis, 1077 
tumors of, 1079 

differentiation of, 
from syphilis, 283 
pathology, 1079 
symptoms of, 1079 
tuberculosis of, 346 
Meningismus, 1055 
Meningitis, 1041 

bacteriology of, 1043 
chronic, 1056 

differentiation of. from influenza, 
181 
from typhus fever. 60 



INDEX 



1305 



Meningitis, epidemic cerebrospinal, 1045 
bacteriology of, 1045 
clinical forms of, 1049 
complications of, 1049 
etiology of, 1045 
pathology of, 1046 
prognosis of, 1049 
sequelae of, 1049 
symptoms of, 1046 
treatment of, 1055 
pneumococcic, 148 
etiology of, 1042 
in influenza, 178 
serous, 1052 

diagnosis of, 1052 
differentiation of, 1054, 1055 
from brain abscess, 1017 

disease, 1055 
from hysteria, 1055 
from labyrinthitis, 1055 
from typhoid fever, 1055 
symptoms of, 1052 
suppurative, 1043 

diagnosis of, 1052 
differentiation of, from epi- 
demic, 1054 
from brain abscess, 1017, 

1018 
from tuberculous, 1054 
pathology of, 1043 
symptoms of, 1044 
treatment of, 1055 
syphilitic, 282 
tuberculous, 316, 1049 
diagnosis of, 1052 
differentiation of, from epi- 
demic, 1054 
from suppurative, 1054 
from syphilis, 283 
etiology of, 1049 
pathology of, 1050 
symptoms of, 1051 
treatment of, 1055 
in typhoid fever, 28 
Meningococcus intracellularis, 1043,1045 
Meralgia paraesthetica, 1179 
Merycismus, 646 

Mesenteric glands, suppuration of, in 
typhoid fever, 32 
tuberculosis of, 340 
vessels, dilatation of, 691 
embolism of, 691 
periarteritis of, 691 
Mesenteritis, 690, 764, 763 
Mesentery, diseases of, 690 
embolism of, 691 
hemorrhage of, 691 
inflammation of, 690 
suppuration of, 691 
tumors of, 691 
Metabolism, diseases of, 903 
Metatarsalgia, 1232 
Meteorism in typhoid fever, 32 
Micrococcus catarrhalis, 496 

melitensis, 233 
Microgastria, 617 



Micromania, 1023 
Micromegaly, 899 
Migraine, 1226 

diagnosis of, 1228 
etiology of, 1226 
ophthalmoplegic, 1151 
prognosis of, 1227 
symptoms of, 1226 
treatment of, 1228 
Mikulicz's disease, 580, 865 
Miliaria, differentiation of, from chicken- 
pox, 83 
in pneumonia, 146 
in typhoid fever, 24 
Miliary fever, 372 
tuberculosis, 313 

differentiation of, from influ- 
enza, 181 
from sepsis, 135 
from typhoid fever, 42, 44, 
45 
Milk sickness, 374 

poisoning, 1252 
Millar's asthma, 185, 897 
Mimetic movements of expression, 954 
"Mind blindness," 946, 947 

centres for, 947 
Mitral insufficiency, 407 

diagnosis of, 409, 412 
etiology, 407 
mechanism of, 407 
physical signs of, 408 
stenosis, 410 

diagnosis of, 411 
differentiation of, 412, 449 
etiology of, 410 
mechanism of, 410 
physical signs of, 410 
prognosis of, 412 
treatment of, 423 
Mobius' sign, 890 
Mogigraphia, 1221 
Moller's disease, 872 
Monoplegia, in cerebral thrombosis, 986 
cortical, 943 

internal capsule lesion in, 953 
Morbilli, 96 
Morbus caeruleus, 433 
coxae senilis, 928 
maculosus neonatorum, 869 
Werlhofii, 868 
Morphinism, 1246 
Morphinomania, 1246 
Morvan's disease, 1111 
Mosquito, conveyance of malaria by. 114 

yellow fever, 213 
Motor insufficiency of stomach, 610 

tracts, 1058, 1060, 1061 
Mountain fever, 374 
Mouth, diseases of, 573 
syphilis of, 270 
washes, 574, 575, 576 
Movable kidney, 795 

spleen, 884 
Mucin, tests for. S01 



1306 



IXDEX 



Mucous colic, differentiation of, from 

gall-stones, 733 
Mucus casts, of bowel, 654 
Muguet, 575 
Multiule neuritis, 1141 

sclerosis, 1103 
Mumps, 188 

complications of, 189 
course of, 189 
diagnosis of, 190 
etiology of, 188 
prognosis of, 190 
sequels of, 189 
symptoms of, 188 
treatment of, 190 
Muscles, diseases of, 1238 

sense, in cortex lesions, 946 
syphilis of, 293 
tuberculosis of, 357 
in typhoid fever, 29 
Muscular atrophy, neuritic, 1131 
progressive spinal, 1128 

diagnosis of, 1130 
differentiation of , 1130 
etiology of, 1128 
pathology of, 1129 
prognosis of, 1131 
symptoms of, 1129 
treatment of, 1131 
dystrophy, 1132 

diagnosis of, 1134 
differentiation of, 1135 
infantile atrophic, 1133 
juvenile, 1134 
pseudohypertrophic, 1132 
treatment of, 1135 
Myalgia, 1239 
capitis, 1239 
rheumatic, 197 
Myasthenia, gastric, 612 
gravis, 1032 

differentiation, from polien- 

cephalitis, 1012 
pseudoparalytica, 1032 
Myasthenic reaction, 1032 
Mycosis intestinalis, 242 
Mycotic plugs, 499 
Mydriasis, syphilitic, 289 
Myelasthenia, 1194 
Myelitis, acute, 1089 

course of, 1093 
diagnosis of, 1093 
differentiation of, from hys- 
teria, 1094 
disseminated, 1095 
etiology of, 1089 
localization of, 1092 
pathology of, 1090 
prognosis of, 1093 
symptoms of, 1090 
transverse, 1095 
treatment of, 1094 
annular, 1090 
chronic, 1095 
compression, 1071 
cortical, 1090 



Myeloid leukaemia, 857 

Myeloma, multiple, differentiation of, 

865 
Myelomalacia, 1083 
Myocarditis, acute, 444 

circumscript, 445 
diagnosis of, 445 
etiology of, 444 
pathology of, 444 
symptoms of, 445 
treatment of, 445 
chronic fibrous, 446 

diagnosis of, 448 
differentiation of, 449 
etiology of, 446 
pathogenesis of, 447 
pathology of, 446 
prognosis of, 449 
symptoms of, 448 
treatment of, 449 
in diphtheria, 168 
rheumatic, 196 
segmentary, 445 
syphilitic, 277 
in typhoid fever, 25 
Myocardium, diseases of, 434 
fragmentation, 445 
myofibrosis, 446, 447 
myolysis, 446 
myomalacia cordis, 447 
parasites of, 451 
segmentation, 445 
tuberculosis, 356 
tumors of, 451 
Myoclonia, 1216 

Myofibrosis, myocardii, 446, 447 
Myoidema, 335 
Myolysis in diphtheria, 168 

myocardial, 446 
Myomalacia, cordis, 447 
Myopathies, progressive, 1132 
Myositis, 1238 

ossificans, 1239 
rheumatic, 197 
syphilitic, 293 
Myotonia, 1222 

etiology of, 1222 
symptoms of, 1222 
treatment of, 1222 
Mytilotoxismus, 1252 
Myxcedema, 893 
of adults, 894 
differentiated, from exophthalmic 

goitre, 888 
operative, 895 
Myxoma of thyroid gland, 887 



N 



Nasal chancre, 278 

feeding in typhoid fever, 51 

gumma, 278 
Nasopharynx, tuberculosis of, 354 
Nauheim baths in heart disease, 437 
Neck, actinomycosis of, 257 



INDEX 



1307 



Negri bodies in hydrophobia, 254 
Nematodes, diseases caused by, 1264 
Neoplasms of spleen, 883 
Nephritis, acute, 767 
course of, 772 
diagnosis of, 770 
differentiation of, 770, 796, 797 
from amyloid kidney, 796, 

797 
from chronic, 796, 797 
from congestion, 796, 797 
etiology of, 767 
pathology of, 768 
prognosis of, 771 
symptoms of, albuminuria, 769 
anaemia, 770 
anasarca, 770 
casts, 769 
heart, 770 
hydrops, 770 
urine, 768 
treatment, 772 
types of, cholera, 771 

haemoglobinuric, 771 
kidney of pregnancy, 771 
recurrent, 771 
chronic, 774 

interstitial, 777 

complications of, 783 
diagnosis of, 784 

of cardiac symptoms, 

784 
of uraemia, 784 
of urinary findings, 
784 m 
differentiation of, from 
acute nephritis, 796, 
797 
from amyloid kidney, 

796, 797 
from chronic paren- 
chymatous, 796, 797 
from congested kid- 
ney, 796, 797 
etiology of, 778 
pathology of, 778 
prognosis of, 785 
symptoms of, 779 

cardiovascular, 780 
digestive, 783 
hemorrhages, 783 
inflammations, 783 
oedema, 783 
retinitis, 781 
uraemia, 781 
urinary, 779 
treatment of, 785 
parenchymatous, 774 

complications of, 777 
death in, causes of, 777 
diagnosis of, 777 
differentiation of, from 
acute nephritis 796, 
797 
from amyloid kidney, 
796, 797 



Nephritis, chronic, parenchymatous, dif- 
ferentiation of, from 
congested kidney, 
796, 797 
from interstitial neph- 
ritis, 796, 797 
etiology of, 774 
pathology of, 774 
prognosis of, 777 
symptoms of, 775 
anaemia, 776 
cardiovascular, 777 
oedema, 776 
urinary of, 776 
treatment of, 785 
treatment of, bleeding, 790 
climate, 786 
diet, 786 
diuretics, 788 
heart stimulants, 790 
incisions, 789 
lumbar puncture, 790 
oedema, 788 
rest, 785 
sweating, 788 
vasodilators, 790 
venesection, 790 
water, 788 
in cirrhosis of liver, 700 
diphtheritic, 168 
in malaria, 120 
in pneumonia, 147 
suppurative, 809, 812 
scarlatinal, 89, 95 

treatment of, 95 
syphilitic, acute, 276 

chronic, 276 
tuberculous, 311 
typhoid, 37 
Nephrolithiasis, 817 
Nerves, anterior crural, 1179 
auditory, paralysis of, 1163 
brachial plexus, 1178 
cerebral, syphilis of, 282, 289 
circumflex, 1176 
cranial, diseases of, 1146 
diseases of, 1139 
eighth, disease of, 1163 
eleventh, disease of, 1172 
facial, paralysis of, central, 1161 
peripheral, 1158 
spasm of, 1163 
fifth, paralysis of, 1155 

spasm of, 1157 
fourth, diseases of, 1149, 1151 
glossopharyngeal, 1166 
hypoglossal, diseases of, 1174 
lumbar plexus, 1179 
median, 1177 
musculospiral, 1176 
ninth, 1166 
obturator, 1179 
olfactory, 1146 
optic, 1146 
peroneal, 1180 
phrenic, 1174 



1308 



INDEX 



Nerves, popliteal, 1180 

posterior thoracic, 1176 

recurrent laryngeal, paralysis of/476 

spasm of. 477 
sacral plexus, 1180 
sciatic, 1180 

seventh, diseases of, 1158 
sixth, diseases of, 1149, 1151 
spinal accessory, paralysis of, 1172 
spasm of, 1172 

diseases of, 1174 
superior gluteal, 1180 
suprascapular, 1176 
syphilis of, 282, 286, 289 
tenth, 1167 

third, diseases of, 1149, 1151 
twelfth, diseases of, 1174 
ulnar, 1177 
vagus, 1167 
Nervous fever, 27 
diseases, 941 
vomiting, 645 
Neuralgia, 1229 
diabetic, 911 
etiology of, 1229 
in influenza, 178 
in malaria, 121 
symptoms of, 1230 
treatment of, 1233 
in tuberculosis, 334 
varieties of, cervicobrachial, 1232 

cervico-occipital, 1231 

intercostal, 1232 

lumbar, 1232 

phrenic, 1231 

sacral, 1232 

trifacial, 1230 

visceral, 1232 
Neurasthenia, 1193 
course of, 1197 
diagnosis of, 1197 
differentiation of, from paretic 

dementia, 1026 
etiology of, 1193 
prognosis of, 1197 
symptoms of, 1194 

cardiac, 452 
treatment of, 1194 
types of, 1194 
Neuritis, 1139 

brachial, 1178 

diabetic, 911 

diagnosis of, 1141 

in diphtheria, 167 

etiology of, 1139 

in influenza, 178 

lead poisoning causing, 1249 

multiple, 1141 

diagnosis of, 1144 

differentiation of, 1144 

etiology of, 1142 

pathology of, 1 142 

prognosis of, 1143 

symptoms of, 1142 

treatment of, 1145 
optic, 1147 



Neuritis, pathology of, 1139 

rheumatic, 199 

sciatic, 1181 

symptoms of, 1139 

treatment of, 1141 

in tuberculosis, 334 

in typhoid fever, 29 
Neuroma, 1145 
Neurones, 1057 

motor, 1058 
Neuroses, 1184 

fatigue, 1221 

of heart, 451 

occupation, 1221 

of stomach, 639 

traumatic, 1199 

diagnosis of, 1200 
etiology of, 1199 
prognosis of, 1201 
symptoms of, 1200 
treatment of, 1201 

trophic, 1234 

in typhoid fever, 29 

vasomotor, 1234 
Nigrities linguae, 578 
Nodes, rheumatic, 196 
Noma oris, 576 

in typhoid fever, 24 
Nose, diseases of, 485 

syphilis of, 278 

tuberculosis of, 354 
Nucleo-albumin, tests for, 801 
Nutmeg liver in heart disease, 421 
Nystagmus, 1154 

in multiple sclerosis, 1105 



Obesity, 936 

in diabetes, 905 

etiology of, 936 

symptoms of, 936 

treatment of, 937 
Ochronosis, 809 

Ocular paralyses, syphilitic, 289 
(Edema, angioneurotic, 1236 

of brain, 964 

cardiac, 422, 427 

of glottis, 493 

in typhoid fever, 35 

hereditary, 1236 

of larynx, 493 

of lungs, 536 

in heart disease, 420 
in rheumatism, 197 

in whooping-cough, 184 
Oertel's cure, 937 

treatment of heart disease, 437 
Oesophagitis, etiology of, 589 

symptoms of, 590 

treatment of, 590 
(Esophagomalacia, 590 
(Esophagus, cancer of, complications, 596 
diagnosis, 596 
etiology of, 595 



INDEX 



309 



(Esophagus, cancer of, pathology, 595 
symptoms, 596 
treatment, 596 
dilatation of, etiology of, 593 
symptoms of, 593 
treatment of, 594 
diseases of, 589 
diverticulum, 594 
hemorrhage of, 597 
measurements of, 592 
necrosis of, 590 
pulsion-diverticulum, 594 
rupture of, 597 
perforation of, 597 
sounding of, 592, 593 
stenosis of, 590 
stricture of, diagnosis, 591 
etiology of, 591 
physical signs of, 591 
prognosis of, 592 
symptoms, 591 
treatment of, 592 
syphilis of, 271 
traction-diverticulum, 595 
tuberculosis of, 347 
tumors of, benign, 596 
typhoid ulceration of, 31 
ulceration of, 590 
varices of, 699 
Oidium albicans, 575 
Oligocardia, 456 
Oligochromsemia, 832 
Oligocythemia, 832 
Ophthalmia, diphtheritic, 166 
Ophthalmoplegia, progressive nuclear, 
1153 
syphilitic, 289 
Ophthalmoplegic encephalitis, acute, 1011 
Opisthorchis siensis, 1276 
Opium, coma from, 975 
poisoning, acute, 1245 
chronic, 1246 
Oppler-Boas bacillus, 634, 635 
Optic atrophy, syphilitic, 289 
nerve, 1146 
neuritis, syphilitic, 284 

in typhoid fever, 29 
thalamus, localizing symptoms, 954 
Orchitis, in mumps, 189 
syphilitic, 290 
in typhoid fever, 38 
Osteitis deformans, 900 
Osteo-arthropathic hypertrophiante, 503 

pneumonique, 900 
Osteo-arthropathy, hypertrophic, 900 
Osteochondritis, syphilitic, 297 
Osteomyelitis. See Septic Affections, 133 

in typhoid fever, 29 
Otitis, diphtheritic, 166 

media, brain abscess from, 1014 
sinus thrombosis from, 991 
rheumatic, 192 
scarlatinal, 90, 94 
treatment of, 94 
Ovarian cyst, differentiation of, from 
ascites, 760 



Ovarian tumor, differentiation of, from 

hydronephrosis, 816 
Ovary, syphilis of, 292 
Oxalate calculus, 818 
Oxaluria, 808 
Oxyuris vermicularis, 1266 



Pachymeningitis, cervical hypertro- 
phic 1077 
diagnosis of, 1078 
pathology of, 1077 
symptoms of, 1078 
treatment of, 1078 
external, 1037 

hemorrhagic, diagnosis of, 1040 
differentiation of, 1040 
etiology of, 1038 
pathology of, 1038 
prognosis of, 1039 
symptoms of, 1039 
treatment of, 1040 
internal, 1037 
Paget's disease, 900 
Pain, centre for, 947 
Palate, tuberculosis of, 347 
Palpitation of heart, 451 
Palsy, shaking, 1223 
Pancreatic cancer, differentiation of, 750 

symptoms, 749 
Pancreas, calculi of, 747 

cancer of, differentiation of, from 

gall-stones, 750 
cysts of, 748 

diagnosis of, 748 
etiology of, 748 
pathology of, 748 
symptoms of, 748 
treatment of, 749 
diseases of, 743 
hemorrhage from, 747 
inflammation of, acute, 743 

chronic, 746 
syphilis of, 273 
tumors of, 749 

differentiation of, 750 

from cancer of stomach, 636 
symptoms of, 749 
treatment of, 751 
Pancreatitis, acute, diagnosis of, 745 
differentiation, 745 
etiology of, 743 
gall-stones in, 732 
prognosis of, 745 
symptoms, 743 
treatment of, 745 
chronic, etiology of, 746 
gall-stones in, 732 
pathology of, 746 
prognosis of, 746 
symptoms of, 746 
treatment of, 747 
Paracolon infection, 43 
Paresie analgesique avec panaris, 1111 



1310 



INDEX 



Paragonius Westermanni, 1275 
Parkinson's disease, 1223 
Paralysis. See Monoplegia, Hemiplegia, 
Paraplegia 
agitans, 1223 

diagnosis of, 1225 
differentiation of, from multi- 
ple sclerosis, 1107 
etiology of, 1223 
pathology of, 1223 
prognosis of, 1225 
symptoms of, 1223 
treatment of, 1225 
anterior crural, 1179 
of auditory nerve, 1163 
Bell's, 1158 
brachial plexus, 1178 
Brown-Sequard's, 1086 
bulbar, apoplectiform, 1033 
asthenic, 1032 
chronic, 1029 
caisson, 1085 
circumflex, 1176 
combined, of arm nerves, 1178 
compression, spinal, J. 071 
conjugate, 957 
cortical, 943 
diphtheritic, 166 
diver's, 1085 
facial, 1158 _ 

diagnosis of, 1161 
etiology of, 1158 
localization of, 1161 
pathology of, 1159 
prognosis of, 1162 
symptoms of, 1159 
in tetanus, 250 
treatment of, 1162 
of fifth nerve, 1155 
Gublers', 957 
hypoglossal, 1174 
infantile cerebral, 994 
diplegic, 996 

diagnosis of, 999 
etiology of, 996 
pathology of, 996 
symptoms of, 997 
treatment of, 999 
hemiplegic, 995 

diagnosis of, 996 
etiology of, 995 
symptoms of, 995 
treatment of, 999 
of insane, 1020 
labioglossopharyngeal, 1029 
Landry's, 1102 
laryngeal, 1168 

■ recurrent, 1168, 1169 
lumbar plexus, 1179 
in malaria, 121 
median, 1177 
musculospiral, 1176 
obturator, 1179 
ocular, 1149 
oculomotor, 956, 959 
periodic family, 1225 



Paralysis, peroneal, 1180 

phrenic, 1174 

popliteal, 1180 

posterior thoracic, 1176 

pseudobulbar, 1031, 1034 

pseudo-, syphilitic, 873 

sciatic, 1180 

spinal accessory, 1172 

superior gluteal, 1180 

suprascapular, 1176 

of sympathetic nerves, 1154 

syphilitic, 284 

ulnar, 1177 

vagus, 1167 

of vocal cords, 1168 

Weber's, 956 
Paramyoclonus multiplex, 1216 
Paramyotonia, ataxic, 1223 

congenital, 1222 
Paranephritis, 812 
Paraplegia ataxic, 1137 

in cerebral infantile paralysis, 998 

hysterical, 1094, 1188 

spastic spinal, 1124 
Parapleuritis, 554 
Parasecretion, gastric, 642 
Parasites, diseases due to animal, 1257 

of heart, 451 

of lungs, 540 
Parasitic stomatitis, 575 
Parathyroid glands, 896 
Paratyphoid fever, 19, 43 

differentiation of, from typhoid 

fever, 43 
microorganisms of, 43 
symptoms of, 43 
Parenchymatous nephritis, chronic, 774 
Parorexia, 648 
Parosmia, 1146 
Parotitis, acute, 579 

chronic, 580 

epidemic, 188 

post-operative, 190 

secondary, 190 

in typhoid fever, 30 
Paroxysmal hemoglobinuria, 804 
Parrot's disease, 873 

ulcers, 575 
Pavor nocturnus, 588 
Peliosis rheumatica, 867 
Pellagra, 1253 

differentiation of, from Addison's 
disease, 880 
Pelvis, rhachitic, 933 
Pemphigus, differentiation of, from 

chickenpox, 83 
Penis, syphilis of, 290 
Pentosuria, 915 

Pepsin, test for in stomach, 605 
Peptone, tests for, 801 
Perforation, intestinal, in typhoid fever, 
34 

of oesophagus, 597 
Periarteritis of mesenteric vessels, 691 

nodosa, 483 



INDEX 



1311 



Pericarditis, 377 
adhesive, 387 

diagnosis of, 389 
prognosis of, 389 
symptoms of, 387 

cardiac insufficiency, 387 
diastolic collapse of veins 
388 
recoil, 388 
inspiratory swelling of 

veins, 389 
paradoxical pulse, 388 
retraction of apex, 388 
of chest wall, 388 
treatment of, 389 
differentiation of, from pleurisy, 557 
effusive, 378 

course of, 386 
diagnosis of, 383 

character of exudate, 385 
dulness, 384 
friction rub, 383 
pathology of, 379 
physical signs of, 380 
prognosis of, 386 
symptoms of, 379 
treatment of, 386 
etiology of, 377 
externa, 379 
fibrinous, 378 

physical findings of, 378 
symptoms of, 378 
pneumococcic, 148 
pseudocirrhosis of liver in, 702 
rheumatic, 195 
scarlatinal, 88 
syphilitic, 277 
tuberculous, 334, 341 
in typhoid fever, 25 
Pericardium, diseases of, 377 

tuberculosis of, 341 
Perichondritis, laryngeal, in typhoid 
fever, 35 
of larynx, 493 
Perihepatitis, 758 

differentiation of, from ascites, 764 
from cirrhosis of liver, 702, 764 
from peritoneal cancer, 764 
from tuberculous peritonitis, 
764 
Perinephric abscess, 812 
diagnosis of, 813 
etiology of, 812 
symptoms of, 813 
Perinephritis, 812 
Periostitis, rheumatic, 197 
syphilitic, 292 
_ in typhoid fever, 29 
Peripheral nerves, diseases of, 1139 
Peripleuritis, 554 
Perisplenitis, 883 
Peristaltic unrest, gastric, 644 
Peritoneum, cancer of, 758, 764 

differentiation of, from ascites, 
764 
from hepatic cirrhosis, 764 



Peritoneum, cancer of, differentiation of, 
from tuberculous peri- 
tonitis, 764 
from perihepatitis, 764 
diseases of, 751 
tuberculosis of, 341 
Peritonitis in cirrhosis of liver, 700 
diffuse, acute, 751 

course of, 753 
differentiation of, 754 
diagnosis of, 754 
etiology of, 751 
perforative, 754 
pneumococcic, 754 
symptoms of, abdominal, 
752 
general, 753 
local, 752 
treatment of, 755 
types of, 753 
chronic, 755 

differentiation of, from 
portal cirrhosis of liver, 
702, 764 
deforming, 755 
hemorrhagic, chronic, 758 
localized, 756 

adhesive, 757 

perihepatitis, 758 
suppurative, 756 

pyopneumothorax, sub- 

phrenicus, 756 
subphrenic abscess, 756 
tuberculous, 336, 341 

differentiation of, from ascites, 
762 
from hepatic cirrhosis, 762 
from perihepatitis, 764 
from peritoneal cancer, 764 
typhoid perforation, causing, 34 
Peritonsillar abscess, 586 
Perityplitis, 664 
Perles, asthma, 508 
Pernicious ansemia, 839 

differentiation of, from gas- 
tric cancer, 634, 635 
Pertussis, 182. See Whooping-cough. 
Pest, 219 

Pesticaemia in plague, 220 
Petechias, in typhus fever, 57 
Petit mat, 1204 
Pharyngeal tonsil, 587 
Pharyngitic diphtheria, 163 
Pharyngitis, acute, 581 
chronic, 582 
phlegmonous, 583 
ulcerative, 583 
Pharynx, diseases of, 581 
erysipelas of, 106, 107 
tuberculosis of, 347 
typhoid ulcers of, 31 
ulceration of, 583 
Phenylhydrazin test, 907 
Phlebitis, pneumococcic, 14S 
portal vein, 722 
syphilitic, 278 



1312 



INDEX 



Phlegmon, differentiation of, from 

erysipelas, 107 
Phlegmonous enteritis, 655 
Phloridzin test, 780 
Phosphate calculus, 818 
Phosphates in urine, 807 
Phosphatic calculus, 818 
Phosphaturia, 807 
Phosphorus poisoning, 694 
Phthisis, 303, 318 
aneurysmal, 477 
fibroid, 520 
ventriculi, 609 
Pigeon-breast, 588 
Pigmentary cirrhosis of liver, 702 
Pigmentation of oral cavity in Addison's 

disease, 879 
Piles, 683 

Pityriasis, tuberculous, 336 
Placenta, syphilis of, 291 
Plague, 219 

diagnosis of, 223 
etiology of, 219 
prognosis of, 224 
symptoms of, 220 
treatment of, 224 
Plasmodium malariae, 109 
Pleura, diseases of, 542 
tuberculosis of, 341 
tumors of, 569 
Pleurisy, 542 

bacteriology of, 543 
course of, 555 
cytodiagnosis in, 551 
diagnosis of, 557 
differentiation of, 557 

from abscess of liver, 559 

of effusion, 558 

from enlargement of liver, 559 

of spleen, 559 
of friction rub, 557 
from hydrothorax, 558 
from lung cavities, 559 
from pericarditis, 557 
from pneumonia, 153, 558 
from pneumothorax, 565 
from rales, 557 
from subphrenic abscess, 559 
empyema, 551 

necessitatis, 552 
pneumococcic, 552 
pulsans, 552 
streptococcic, 551 
etiology of, 542 
forms of, 551 

in children, 554 
chyliform, 553 
diaphragmatic, 553 
fibrinous, 551 
hemorrhagic, 553 
interlobar, 554 
mediastinal, 554 
parapleuritis, 554 
peripleuritis, 554 
purulent, 551 
putrid, 553 



Pleurisy, forms of, serous, 551 
suppurative, 551 
in influenza, 179 
issues of, 556 
pneumococcic, 147 
physical signs of, 544 

auscultation, 548 
diagnostic puncture, 549 
inspection, 544 
palpation, 545 
percussion, 546 
prognosis of, 559 
rheumatic, 197 
symptoms of, 550 
treatment of, 560 

aspiration, 561 
in tuberculosis, 333 
in typhoid fever, 36 
Pleuritic friction, 545, 548 
Pleurodynia, 1239 
Pleuroperi cardial friction, diagnosis of, 

384 
Pleuropneumonia, 136 
Plumbism, 1247 

differentiation of, 1026 
Pneumatosis peritonei, 754 
Pneumaturia, 910 
Pneumobacillus, 137 
Pneumococcsemia, 137 
Pneumococcic pharyngitis, 581 
Pneumococcus. See Septic Affections 

endocarditis, 396 
Pneumohsemia, 137, 146 
Pneumokoniosis, 522 
etiology of, 522 
pathology of, 522 
symptoms of, 523 
treatment of, 524 
Pneumomalacia, 529 
Pneumonia, 136 
aspiration, 515 
bacteriology of, 136 

pneumobacillus, 137 
pneumococcus, 136 
central, 143, 152 
cerebral, 152 

clinical types and variations of, 149 
complications of, 147 
abscess of lung, 149 
alimentary, 149 
arteritis, 148 
arthritis, 149 
empyema, 148 
endocarditis, 148 
gangrene of lung, 149 
gastritis, 149 
icterus, 149 

induration of lung, 149 
joint, 149 
lung, 149 
nervous, 148 
pericarditis, 148 
pleurisy, 147 
pulmonary, 149 
thrombophlebitis, 148 
crossed, 143 






INDEX 



1313 



Pneumonia, death mechanism in, 147 
diagnosis of, 151 

differentiation of, from lung tumor, 
153 

from pleurisy, 152, 153 

from tuberculous pneumonia, 
153 

from typhoid fever, 42 
erysipelatous, 106 
etiology of, 136 
frequency of, 136 
hepatization in, gray, 143 

red, 143 
immunity from, 137 
indurative, 520 

diagnosis of, 522 

etiology of, 520 

pathology of, 521 

physical findings of, 521 

prognosis of, 522 

symptoms of, 521 

treatment of, 522 
interstitial, 520 
Litten's sign in, 143 
lobar, complications of, abscess of 
lung, 520 
gangrene of lung, 528 
induration of lung, 520 

differentiation of, from bron- 
chopneumonia, 519 
from pleurisy with effu- 
sion, 558 
from tuberculous pneu- 
monia, 327 

in influenza, 179 

in typhoid fever, 36 

in whooping-cough, 184 
massive, 150, 152 
migratory, 150 
pathology of, 142 
physical signs of, 143 
pleurogenous, 521 
prognosis of, 153 
rheumatic, 197 
"schluck," 515 
secondary, 515 
symptoms of, 138 

chill, 139 

circulatory, 145 

digestive, 146 

fever, 139 

lymph glands, 146 

nervous, 147 

respiratory, 141 

skin, 146 

urine, 146 
syphilitic interstitial, 281 
total, 150, 152 
treatment of, 154 

diet, 155 

hygienic, 155 

prophylactic, 154 

serotherapy, 155 

symptomatic, 155 
white, syphilitic, 280 
Pneumonitis, 136 
83 



Pneumopericardium, 390 
Pneumoperitoneum, 754 
Pneumorrhagia, 537 
Pneumothorax, 563 

diagnosis of type of. 566 
differentiation of, 566 

from emphysema of lungs, 514 
etiology of, 563 
pathology of, 563 
physical signs of. 564 
prognosis of, 567 
symptoms of, 564 
treatment of, 567 
in tuberculosis, 333 
Podagra. See Gout 
Pododynia, 1232 
Poisoning, arsenical, 1251 
cheese, 1252 
fish, 1252 
food, 1251 
grain, 1253 
lead, acute, 1248 
chronic, 1248 
milk, 1252 
opium, acute, 1245 
chronic, 1246 
potato, 1254 
Poliencephalitis, inferior, 1012 

superior, 1012 
Poliencephalomyelitis, 1012 
Poliomyelitis, acute, in adults, 1101 
of children, 1095 

diagnosis of, 1099 
differentiation of, 1099 
from cerebral palsies 

996, 1100 
from multiple neuritis, 

1099 
from muscular atro 
phy, 1099 
from myelitis, 1100 
etiology of, 1096 
pathology of, 1096 
prognosis of, 1100 
symptoms of, acute stage, 
1097 
chronic stage, 1099 
degenerative stage, 

1098 
localization, 1098 
treatment of, 1100 
chronic, 1101 
subacute, 1101 
Pollakiuria, 779 
Polysesthesia, tabetic, 1117 
Polyarthritis, rheumatic, 192 
Polycardia, 454 

Polycythemia, with splenic tumor, 8S5 
Polyglobulism, 885 
Polymyositis, 1238 
Polyneuritis endemica, 236 
Polyorrhomenitis, 341 
Polyphagia, 648 
Polysarcia adiposa, 936 
Polyuria in cerebral syphilis, 2S2 
* diabetic. 907, 919 



1314 



INDEX 



Polyuria in malaria, 120 
in typhoid fever, 37 
Pons, localizing symptoms, 957 
Porencephalia, 997 
Portal cirrhosis of liver, 695 
vein phlebitis, 722 
thrombosis, 722 
Posthemorrhagic anaemia, acute, 847 

chronic, 849 
Postmortem tubercles, 358 
Potato poisoning, 1254 
Pott's disease, 1071 
Pox, 262 

Pregnancy, effect of syphilis on, 291 
kidney of, 771 
tuberculosis and, 336 
Prison fever, 55, 61 
Profeta's law, 296 
Prosopalgia, 1230 
Prosoplegia, 1158 
Prostate, tuberculosis of, 353 
Prostitution, regulation of, 298 
Pseudodiphtheria, 159 
Pseudohydrophobia, 255 

differentiation of, from hydropho- 
bia, 255 
Pseudoleukemia, 860 
allied affection, 863 
course of, 862 
diagnosis of, 863 
differentiation of, 863 

from anaemia infantum pseudo- 

leukaemica, 863 
from lymphosarcomatosis, 864 
from multiple myeloma, 865 
from other splenic enlarge- 
ments, 864 
from splenic anaemia, 864 
from tuberculous adenitis, 863 
etiology of, 860 
pathology of, 861 
symptoms of, 860 
blood, 861 
bone, 861 
fever, 862 
lvmph glands, 860 
skin, 862 
spleen, 861 
treatment of, 865 
Pseudomeningitis, 1055 
Pseudoparalysis, syphilitic, 873 
Pseudorheumatism, 201 
Pseudosclerosis (multiple), 1108 
Pseudotetanus, 250 
Pseudotuberculosis, 307, 332 
aspergillus, 307, 332 
protozoan. 307 
streptothrix, 307, 332 
Psoriasis of tongue, 577 
Psychoses, rheumatic, 199 
tuberculous, 311 
in typhoid fever, 28 
Ptosis, 1150 
Ptyalism, 578 

Puerperal fever. See Septic Affections, 
erysipelatous, 106, 108 



Puerperal fever, lymphangitis, 135 

peritonitis, 134 

sapraemia, 134 

scarlatiniform rashes in, 84 

thrombophlebitis, 134 
Pulmonary artery, syphilis of, 278 
distention in heart disease, 420 
embolism, in typhoid fever, 26 
gumma, 280 

hypostasis in typhoid fever, 35 
infiltration, syphilitic, 280 
insufficiency, 412 

etiology of, 412 

mechanism of, 413 

symptoms of, 413 
stenosis, 413 

congenital, 430 

diagnosis of, 414 

etiology of, 413, 430 

mechanism of, 413 

signs of, 413 
Pulsating pleural effusions, 552 
Pulse, alternans, 458 
bigeminus, 419 
collapsing, 403 
liver, positive, 415, 416 
"pistol," 403 
Quincke's capillary, 402 
venous, negative, 416 

positive, 415 
"water-hammer," 403 
Pulsus paradoxus, 388 
Pupil, reflexes of, 1067 

Wernicke's hemianopsic reaction, 
1149 
Purpura, fulminans, 869 
hemorrhagica, 868 

diagnosis of, 868 

etiology of, 868 

prognosis of, 869 

symptoms of, 868 

treatment of, 869 
Henoch's, 868 
renal, 802 
rheumatica, 867 

diagnosis of, 867 

prognosis of, 867 

symptoms of, 867 

treatment of, 868 
simplex, 866 
symptomatic, 866 
visceral crises in, 867 
Pus in urine, 805 
Pustule, malignant, 240 

differentiation of, from ery- 
sipelas, 107 
Pyaemia, 129 
Pyelitis, 809 

complications of, 811 
diagnosis of, 811 
differentiation of, 811 
etiology of, 809 
pathology of, 810 
prognosis of, 811 
symptoms of, 810 
treatment of, 812 



INDEX 



1315 



Pyelitis, in typhoid fever, 37 
Pyknocardia, 454 
Pylephlebitis, 722 

diagnosis of, 723 

etiology of, 722 

suppurative, 723 

symptoms of, 723 

treatment of, 723 
Pylethrombosis, 722 

differentiation of, from cirrhosis 
of liver, 702 
Pyloric insufficiency, 646 

spasm, 644, 624 

stenosis, 611 

benign, 615 
Pylorus, hypertrophy of, 636 

insufficiency of, 646 

spasm of, 624, 643, 644 
Pyocyaneus. See Septic Affections 
Pyramidal tracts, 1059, 1060, 1061 
Pyuria, 805 

diagnosis of, 805 

etiology of, 805, 810 

renal calculus causing, 820 

symptoms of, 805 

treatment of, 806 



Quincke's pulse, 402 

Quinine in malaria, 127 

administration of, 128 
physiological action of, 128 



Rabic tubercles in hydrophobia, 254 
Rabies, 252 

Rag-sorters' disease, 243 
Rale redux, 146 
Ray fungus, 256 
Raynaud's disease, 1235 
Reaction of degeneration, 1139 
Rectal feeding, 625 
Rectum, cancer of, 677, 679 

syphilis of, 272 
Recurrent fever, 61 

convalescence in, 64 

diagnosis of, 63 

differential, 64 

etiology of, 61 

prognosis of, 64 

symptoms of, 61 

treatment of, 64 
Reichmann's disease, 642 
Relapsing fever, 61 
Ren arcuatus, 795 
Renal calculus, 817 

chemistry of, 817 

complications of, 820 

diagnosis of, 820 

differentiation of, 821 

etiology of, 817 

in gall-stones, 733 



Renal calculus, pathology of, 817 
prognosis of, 821 
symptoms of, 819 
treatment of, medical, 821 
surgical, 822 
cancer, 822 

complications of, 824 
diagnosis of, 824 
differentiation of, from liver 
tumor, 824 
from splenic tumor, 824 
from ovarian tumor, 824 
etiology of, 822 
pathology of, 822 
prognosis of, 824 
symptoms of, 823 
colic, 819 

differentiation of, from gall- 
stones, 733 
echinococcus, 828 

complications of, 829 
symptoms of, 828 
treatment of, 829 
sarcoma, 825 

tumors, differentiation of, from 
cancer of liver, 714 
Rennet, test for, 605 
Rest cure, 1198 
Retina, arteriosclerosis of, 469 
Retinitis, 1146 

albuminuric, 781 
diabetic, 911 
in heart disease, 419 
syphilitic, 288 
Retropharyngeal abscess, 583 
Rhachitis, 931 

acute. See Barlow's disease, 872 
tarda, 932 
Rheumatic fever, 190 

purpura, 867 
Rheumatism, acute articular, 190 
diagnosis of, 190, 200 

anomalous forms, 201 
in childhood, 200 
gonorrhceal, 201 
pseudorheumatism, 

201 
scarlatinal, 201 
differentiation of, 200, 202 
etiology of, 191 
frequency of, 190 
prognosis of, 199, 201 
symptoms of, 192 
arthritis, 192 
blood, 198 
bone, 197 
circulatory, 194 
digestive, 198 
eye, 199 
fever, 193, 195 
general, 192 
genito-urinary, 19S 
muscle, 197 
nervous, 199 
prodromal, 192 



1316 



INDEX 



Rheumatism, symptoms of, pseudorheu- 
matism, 201 
respiratory, 197 
skin, 196 i|g 
treatment of, 202 
diagnostic, 205 
atypical, 195, 201 
cerebral, 194, 199 
chronic, 926 
endocarditis from, 397 
masked, 195 
muscular, 1239 
relations of chorea to, 1211 
scarlatinal, 91, 94 
spinal, 199 
syphilitic, 293 
tuberculous, 357 
visceral, 194 
Rheumatoides, 201 
Rhiga's disease, 574 
Rhinitis, acute, 485 

etiology of, 485 
symptoms of, 485 
treatment of, 486 
chronic, 487 

atrophic, 488 
hypertrophic, 487 
treatment of, 488 
diphtheritic, 164 
fibrinous, 488 
m syphilitic, 278 
Rhizomucor parasiticus, 332 
Rickets, 931 

complications of, 934 
course of, 934 
diagnosis of, 935 
differentiation of, 935 

from hydrocephalus, 1036 
etiology of, 931 
pathology of, 933 
prognosis of, 934 
symptoms of, 932 
treatment of, dietetic, 935 
hygienic, 935 
medicinal, 935 
orthopedic, 936 
Risus sardonicus, 249 
Romberg's sign, 1116 
Rose cold, 486 
Roseola in meningitis, 23 
in pneumonia, 23, 146 
in tuberculosis, 23, 317 
in typhoid fever, 23 
in typhus fever, 52, 57 
Rose spots in miliary tuberculosis, 317 

in typhoid fever, 23 
Rotheln, 102 
Roth's white spots, 132 
Round ulcer, of stomach, 617 
Rubeola, 96 

notha, 102 
Rudimentary kidney, 794 
Rumination, 646 
Rupture of aorta, 483 
of heart, 450 
of oesophagus, 597 



Saddleback nose, 279 
' St. Anthony's fire, 103 
j St. Vitus dance, 1210 
J Saline infusions, 158 
Salivation, etiology of, 578 
symptoms of, 578 
treatment of, 579 
Salivary calculi, 580 

glands, diseases of, 578 

symmetrical hypertrophy of, 

580 
tuberculosis of, 347 
Saprsemia, 129 
Sarcoma of brain, 1000 
of liver, 711 
of gall-bladder, 741 
of intestines, 680 
renal, 825 
Saturnism, 1247 

Scarlatina, differentiation of, from small- 
pox, 67, 76 
from measles, 100 
endocarditis from, 397 
Scarlet fever, 83 

diagnosis of, 90 
differentiation of, 91 

from dermatitis exfolians, 

92 
from diphtheria, 87, 92 
from erysipelas, 92 
from German measles, 92, 

100 
from measles, 92, 100 
from sepsis, 84, 91 
etiology of, 83 
prognosis of, 92 
sequels of, 90 
symptoms of, 85 
blood in, 88 
bones and joints, 91 
cardiac, 88 
digestive, 88 
eruption, 86 
fever, 85 
kidney, 89 

lymphatic glands, 90 
respiratory, 88 
special senses, 90 
stages, 85 
throat, 87 

diphtheria differen- 
tiated, 87 
treatment of, 92 
Schmidt's abdominal reflex, in pleurisy, 

553 
Schoch's, formaldehyde method, 79 
Schott's treatment of heart disease, 437 
Schroth treatment of pleurisy, 560 
Sciatic neuritis, 1181 
Sciatica, 1181 

diagnosis of, 1182 
etiology of, 1181 
pathology of, 1181 
prognosis of, 1182 



INDEX 



1317 



Sciatica, symptoms of, 1181 

treatment of, 1183 
Sclerema adiposum, 660 
Sclerodactylia, 1237 
Scleroderma, 1237 
Scleredema, 660 
Sclerose en plagues, 1103 
Sclerosis, amytrophic lateral, 1126 
diagnosis of, 1128 
etiology of, 1127 
pathology of, 1127 
prognosis of, 1128 
symptoms of, 1127 
treatment of, 1128 
of brain, diffuse, 1028 

lobar, 997 
disseminated, 1103 
insular, 1103 
multiple, 1103 

apoplectiform siezures in, 1106 
course of, 1107 
diagnosis of, 1107 
differentiation of, 1107 

from brain syphilis, 1108 
from brain tumor, 1009 
from hysteria, 1008 
from paralysis agitans, 

1107 
from paretic dementia, 

1025 
from pseudosclerosis, 1108 
from syphilis of brain, 1108 
from tabes, dorsalis, 1122 
etiology of, 1104 
pathology of, 1104 
prognosis of, 1107 
symptoms of, 1104 
treatment of, 1109 
nystagmus in, 1105 
scorbutic, 871 
Scotoma, 1148 
Scorbutus, 870 
Scrofula, 337, 358 
Scrofuloderma, 358 
Scurvy, 870 

course of, 871 
diagnosis of, 872 
etiology of, 870 

infantile, 872. See Barlow's Disease 
prognosis of, 871 
symptoms of, 870 
treatment of, 872 
Secondary anaemia, 847 

post-hemorrhagic, acute, 847 
chronic, 849 
Secretin, 651 

Secretion, continuous gastric, 642 
Semilunar ganglia, in Addison's disease, 
878 
space, 547 
Sensation, cortical representation, 945 
Sensory cross way, 951 
Sepsis, 129 

differentiation of, from malaria, 127 
from measles, 101 
from typhoid fever, 44, 45 



Sepsis, scarlatinal rashes in, 84, 91 
Septic affections, 129 

colon bacillus, sepsis, 133 
diagnosis of, 135 
differentiation of, 135 

from miliary tuberculosis, 

135 
from rheumatism, 135 
from typhoid, 135 
endocarditis, ulcerative, 133 
etiology of, 130 
gonococcic infection, 133 
groups of, 129 
osteomyelitis, 133 
otogenous sepsis, 133 
pathology of, 130 
peritonitis, 134 
pneumococcic infection, 133 
prognosis of. 135 
puerperal fever, 134 
pyocyaneus infection, 133 
staphylococcic infection, 132 
streptococcic infection, 132 
symptoms of, 130 
general, 130 
special, 132 
treatment, 135 
typhoid infection, 133 
diphtheria, 164 
Septicsemia, 129 

in plague, 220 
Septicopyemia, 129 
gonorrhceal, 260 
Serotherapy, in erysipelas, 109 

in scarlatina, 95 
Serous membranes, tuberculosis of, 341 
Serum of dethyroidated animals, 892 
Seven-day fever, 61 
Shaking palsy, 1223 
Sheep-stools, 678 
Shiga's bacillary dysentery, 225 

complications of, 227 
diagnosis of, 227 
pathology of, 226 
prognosis of, 227 
symptoms of, 226 
treatment of, 231 
Ship fever, 55 
Sialodochitis fibrinosa, 580 
Sialolithiasis, 580 

pancreatica, 747 
Sialorrhcea, 578 
Siderosis of lungs, 523 
Singultus, 1175 
Sinus thrombosis, 991 

of cavernous sinus, 993 
diagnosis of, 992 
differentiation, from brain 

abscess, 1017 
etiology of, 991 
of lateral sinus, 993 
pathology of, 991 
prognosis of, 994 
of superior longitudinal sinus, 

992 
symptoms of, 992 



1318 



INDEX 



Sinus thrombosis, treatment of, 994 
Sitotoxismus, 1253 
Situs viscerum inversus, 432, 719 
Skin, bronzing of, 877, 879 
care of, in scarlatina, 93 
diphtheria of, 166 
tuberculosis of, 323, 358 
Skoda's note in pleurisy, 547 

resonance in pneumonia, 144 
Sleeping sickness, 1277 
Slow pulse in typhoid fever, 24 
Smallpox, 64 
black, 71 

complications and sequelae of, 72 
cutaneous, 73 
digestive, 73 
genito-urinary, 73 
locomotor, 73 
nervous, 72 
respiratory, 72 
special senses, 73 
vascular, 72 
diagnosis of, 74 

differentiation of, from chickenpox, 
74 
from drug rashes, 76 
from glanders, 76 
from measles, 75 
from scarlatina, 76 
from syphilis, 76 
from typhus fever, 59 
etiology of, 64 
prognosis of, 76 
symptoms of, 66 

purpura variolosa, 71 
variola confluens, 70 

pustulosa hemorrhagica, 

71 
discreta, 66 
varioloid, 72 
treatment of, 77 

prophylactic, 79 
symptomatic, 80 
vaccination, 77 
Smegma bacillus, 304 
Smell, center for, 947 
"Softening" of brain, 1020 

chronic, 1027 
Solar plexus, in Addison's disease, 878 
Soor, 575 
Spanocardia, 456 
Spasm, cardiac, 644 

of facial nerve, 1163 
of fifth nerve, 1157 
of glottis in whooping-cough, 184 
habit, 1215 
masticatory, 1157 
mobile, 974 
ocular, 1154 
phrenic, 1175 
pyloric, 624, 644 
of spinal accessory nerve, 1172 
vagus, 1167 
of vocal cords, 1169 
Spastic spinal paraplegia, 1124 
Speech, centres for, 947, 948, 952 



Speech, disturbances of, 948 

mechanism of, 948 
Spina ventosa, syphilitic, 293 

tuberculous, 357 
Spinal atrophy, progressive muscular. 
1128 
cord, anaemia of, 1083 
anatomy of, 1057 
concussion of, 1088 
degeneration of, ascending, 
1064 
descending, 1060, 1061 
in pernicious anaemia, 843 
embolism, 1083 
functions of, 1057 
hemorrhage of, 1083 
diagnosis, 1084 
etiology, 1083 
pathology, 1083 
symptoms, 1084 
hypersemia of, 1083 
inflammation of, 1089 
lesions of, in diphtheria, r 167 
localization of, 1062 
physiology of, 1057 
reflexes of, 1067 
symptomatology of, 1057 
syphilis of, 286 
tracts of, motor, 1058 to 1061 

sensory, 1063 
thrombosis, 1083 
transverse lesion of, 1067 
trauma of, 1086 
tumors of, 1079, 1080 
diagnosis, 1081 
localization, 1080 
pathology, 1080 
prognosis, 1082 
symptoms, 1080 
treatment, 1082 
irritation, 1195 
meninges, diseases of, 1076 
paraplegia, spastic, 1124 

diagnosis of, 1126 
etiology of, 1125 
forms of, 1126 
pathology of, 1126 
symptoms of, 1126 
treatment of, 1126 
rheumatism, 199 
Spine. See Vertebrae 1068. 
Spirals, Leyden-Curschmann, 508 
Spirochaete pallida, 263 
Spirillum Obermeyeri, 61 
i Splanchnomegaly, 899 
, Splanchnoptosis, 680 
Spleen, abscess of, 883 
amyloid, 273, 882 
cysts of, 883 
diseases of, 882 
embolism of, 882 
endothelioma of, 883 
enlargement of, differentiation of, 

from pleurisy, 559 
extirpation of, 866, 885 
floating, 884 



inde: 



1319 



Spleen, movable, 884 
neoplasms of, 883 
rupture of, 884 
syphilis of, 273 
tuberculosis of, 316, 350, 885 
tumors of, acute, 882 
chronic, 882, 885 
Splenectomy, 866 
Splenic anaemia, 864 

tumor, in typhoid fever, 22 
Splenitis, acute, 882 
chronic, 882 
suppurative, 883 
Splenomegaly, with polycythemia and 

cyanosis, 885 
Splenopexy, 885 
Spondylitis, ankylosing, 928 
Spondylose rhizomyelique, 928 
Spotted fever, 1049 
Sputum, disinfection and dangers of, 

359 
Staphylococcus. See Septic Affections. 

endocarditis, 396 
Status lymphaticus, 886 

thymicus, 886 
Stegomyia fasciata, 213 
Stellwag's sign, 890 
Stenocardia, 458 
Stenosis, aortic, 405 
of bronchi, 504 
mitral, 410 
of oesophagus, 590 
pulmonary, 413 

congenital, 430 
of trachea, 504 
tricuspid, 417 

congenital, 432 
Stereognostic sense, 946 
Still's disease, 929 
Stokes-Adams syndrome, 443 
Stomach, abscess of, 600 

analysis of contents, 602, 603, 604, 

605 
anomalies of, 616 
arteriosclerosis of, 469 
atony of, 610 
atrophy of, 609 
cancer of, 629 

complications of, 631 
diagnosis of, 635 
differentiation of, gastralgia, 
626 
gastritis, 626 
hyperchlorhydria, 626 
other tumors, 636 
ulcer, 624, 626 
etiology of, 629 
frequency of, 629 
histology of, 630 
localization of, 631 
pathology of, 630 
prognosis of, 636 
symptoms of, 631 
anaemia, 634 
ascites, 635 
cachexia, 634 



Stomach, cancer of, symptoms of, coma, 
635 
constipation, 632 
digestive, 632 
fever, 635 
general, 631 
haematemesis, 632, 634 
metastases, 635 
pain, 632 
phlebitis, 635 
toxaemia, 635 
urine, 635 
vomiting, 632 
treatment of, medical, 636 
surgical, 637 
cardia of, cancer of, 635 
catarrh of, acute, 598 

chronic, 601 
cirrhosis of, 609 
dilatation of, acute, 610 
etiology of, 610 
prognosis of, 611 
symptoms of, 610 
treatment of, 611 
chronic, 611 

complications of, 614 
diagnosis of, 614 
etiology of, 611 
signs of, 613 
symptoms of, 612 
treatment of, 615 
dimensions of, 614 
diseases of, 598 
hemorrhage from, 637 
hemorrhagic erosions of, 624 
hour-glass, 616 
inflation of, 614 
insufficiency of, 612 
lavage of, 607 
motility of, tests, 612, 613 
neuroses of, 639 
mixed, 648 
motor, 644 
secretory, 639 
sensory, 648 
pain in, 619, 626, 640, 647 
perforation of, in cancer, 631 

in ulcer, 623, 629 
round ulcer of, 617 

complications of, 623 
course of, 622 
diagnosis of, 623 
differentiation of cancer, 
624, 626 
duodenal ulcer, 624 
gall-stones, 624 
gastralgia, 626 
gastritis, 626 
hemorrhagic erosions. 

624 
hyperchlorhydria. 626 
pyloric spasm, 624 
etiology of, 617 
frequency of, 617 
localization of, 623 
pathology of, 618 



1320 



INDEX 



Stomach, round ulcer of, prognosis of, 
625 
symptoms of, 619 
general, 619 
hsematemesis, 620 
hyperchlorhydria, 621 
pain, 619 
vomiting, 621 
treatment of, diet, 627 
gastric rest, 625 
hyperacidity, 627 
medicinal, 628 
pain, 627 
prevention, 625 
rest, 625 
surgical, 628 
symptomatic, 628 
types of, 622 
spasm of, treatment, 608 
syphilis of, 271 
tuberculosis of, 347 
tumors of, 632, 633, 636 
ulceration of, 30, 31 
syphilitic, 271 
typhoid, 30, 31 
Stomatitis, aphthous, 575 
etiology of, 575 
symptoms of, 575 
catarrhal, 573 

etiology of, 573 
symptoms of, 573 
treatment of, 573 
epidemic, 375 
gangrenous, 576 
etiology of, 576 
symptoms of, 576 
treatment of, 577 
parasitic, 575 

etiology of, 575 
symptoms of, 576 
treatment of, 576 
ulcerative, 574 

etiology of, 574 
symptoms of, 574 
treatment of, 575 
varieties of, 574 
Stomatomycosis oidica, 575 
Stone of kidney, 817 
Strabismus, 1150 

Strawberry tongue, scarlatinal, 88 
Streptococcus. See Septic Affections. 
in diphtheria, 160 
endocarditis, 396 
in scarlatina, 83 
Streptothricosis, 307, 332 
Streptothrix, pseudotuberculosis, 307, 

332 
Stricture of the bowel, 673 

of oesophagus, 591 
Strongyloides intestinalis, 1274 
Struma lipomatodes aberrans renis, 825 
Strumitis, 887 

Strychnine, poisoning, diagnosis of, 250 
Sublingual gland in mumps, 189 
Submaxillary gland in mumps, 189 
Subphrenic abscess, 756 



Subphrenic abscess, differentiation, from 
pneumothorax, 566 
pyopneumothorax, 756 
Subsultus tendinum in typhoid fever, 28 
Succusio Hippocratis, 566 
Sudor anglicus, 372 
Sugar, tests for, 906 
Summer catarrh, 486 
Sunstroke, diagnosis of, 1254 
etiology of, 1254 
symptoms of, 1254 
treatment of, 1254 
Supernumerary kidney, 794 
Suppuration of mesentery, 691 
Suppurative encephalitis, 1013 
meningitis, 1043 
pylephlebitis, 723 
splenitis, 883 
Suprarenal glands, degenerations of, 881 
diseases of, 877 
physiology of, 877 
tuberculosis of, 877 
tumors of, 881 
Suralimentation, 362 
Sympathetic nerves, irritation of, 1154 

paralysis of, 1154 
Symptomatic purpura, 866 
Synechia pericardii, 387 
Synovitis, syphilitic, 293 
Syphilis, 262 

accidental, 264, 265 
acquired, 263 

associated conditions, 294 
course of, abnormal, 294 
diagnosis of, 298 
etiology of, 263 

accidental, 264 
sexual intercourse, 263 
life assurance in, 295 
symptoms of, 264 
blood, 268 
bone, 292 
chancre, 264 

characteristics, 264 
course of, 265 
differentiation of, 266 
extragenital, 265 
female, 265 
histology of, 265 
male, 264 
perigenital, 265 
circulatory, 277 
aorta, 278 
bloodvessels, 277 
pulmonary artery, 

278 
veins, 278 
ear, 290 
eye, 287 

choroid, 288 
conjunctiva, 287 
cornea, 287 
iris, 288 
muscles, 288 
orbit, 290 
retina, 288 



INDEX 



1321 



Syphilis, acquired, symptoms of, fever, 
267, 268 
gastro-intestinal, 270 

intestine, 272 
mouth, 270 
oesophagus, 271 
pancreas, 273 
rectum, 272 
stomach, 271 
genitalia, 290 
cervix, 291 
ovaries, 292 
penis, 290 
testes, 290 
tubes, 292 
vagina, 291 
vas deferens, 291 
vulva, 291 
gummata of aorta, 278 
of bones, 292 
of brain, 285 
of bronchi, 280 
of ear, 290 
of eye, 287 
of heart, 277 
of intestines, 272 
of joints, 293 
of kidney, 276 
of larynx, 279 
of liver, 274 
of lungs, 281 
of mamma, 294 
of meninges, 282 
of mouth, 271 
of muscles, 294 
of nose, 278 
of oesophagus, 271 
of ovary, 292 
of penis, 290 
of peritoneum, 273 
of pharynx, 271 
of rectum, 272 
of skin, 269 
of spleen, 273 
of stomach, 272 
of tendons, 294 
of testis, 290 
of trachea, 280 
of tubes, 292 
of uterus, 291 
of vagina, 291 
of vessels, 278 
of vulva, 291 
joints, 293 
kidney, 276 
liver, 273 

lymphadenitis, 267 
lymphangitis, 266 
mamma, 294 
muscles, 293 
nervous, 281 
primary lesion, 264 
respiratory, 278 
bronchi, 280 
larynx, 279 
lungs, 280 



Syphilis, symptoms of, respiratory, tra- 
chea, 280 
secondary, 267 

enanthem, 267 
exanthem, 267 
lymphadenitis, 267 
skin, 268 
spleen, 273 
syphilides, 268 
tertiary, 267 
treatment of, 298 

initial stage, 299 
local, 299 
prophylactic, 298 
secondary, 299 
of bones, differentiation of, from 

rickets, 935 
of brain, 280, 1000 

differentiation of, from multi- 
ple sclerosis, 1108 
from paretic dementia, 

1025 
from tabes dorsalis, 1122 
of bronchi, 280 
cachexia, 294 

cerebral diabetes insipidus in, 282 
mellitus in, 282 
polyuria in, 282 
congenital, 296, 298 
diagnosis, ex juvantibus, 302 
differentiation of, from chickenpox, 
83 
from smallpox, 76 
gummata, 263, 267 
hemorrhagica neonatorum, 869 
hereditary, 295 

diagnosis of, 298 
influence on child, 296 
parental, 295 
symptoms of, 296 
incubation of, 263 
of larynx, 279 
leukoplakia, 577 
of liver, differentiation of, from 
abscess, 724 
from cancer, 713, 724 
from portal cirrhosis, 
701, 702, 724 
of lungs, 280 
malignant, 263 
of nose, 278 
parasyphilis, 263 
primary, 263, 264 
residual, 264 
secondary, 263, 267 
of spinal cord, 281 
stages of, 263 
tertiary, 263, 267 
of trachea, 280 
Syringomyelia, 1109 
arthropathies, 1111 
bulbar, 1111 
diagnosis of, 1111 

differentiation of, from leprosy, 1112 
from multiple neuritis, 1112 
from muscular atrophies, 1112 



1322 



INDEX 



Syringomyelis, differentiation of, from 
tabes, 1112 

etiology of, 1105 

felons, 1111 

pathology of, 1109 

prognosis of, 1112 

symptoms of, 1110 

treatment of, 1112 
System diseases, 1113, 1135 



Tabes dorsalis, 1113 

complications of, 1121 
course of, 1121 
diagnosis of, 1121 
differentiation of, 1122 

from brain syphilis, 1122 
from gall-stones, 733 
from multiple sclerosis, 
1123 
etiology of, 1113 
pathology of, 1114 
prognosis of, 1121 
stages of,' 1115 
symptoms of, 1115 
ataxia, 1116 
crises, 1120 
gait, 1116 
motor, 1116 
reflexes, 1118 
Romberg's sign, 1116 
sensory, 1117 
trophic, 1119 
treatment of, 1123 
mesaraica, 340 
Tache bleuatre in typhoid fever, 24 

cerebrale, 1048 
Tachycardia, 454 

diagnosis of, 455 
etiology of, 454 
exophthalmic, 889 
prognosis of, 455 
treatment of, 455 
Taenia curcumerina, 1261 

echinococcus, etiology of, 1262 
localization of, 1264 
multilocular form, 1264 
pathology of, 1262 
symptoms of, 1262 
elliptica, 1261 
mediocanellata, 1260 
nana, 1261 
saginata, 1260 
solium, etiology of, 1257 
symptoms of, 1258 
treatment of, 1259 
Talma-Drummond operation, 703 
Tapeworms, 1257 
Teeth, Hutchinson's, 297 
Tender toes of Hanford in typhoid fever, 

29 
Tendons, syphilis of, 294 
Terminal infections, 130 
Test meal, 602 



Testicles, atrophy of, in mumps, 189 
syphilis of, 290 

differentiation of, from carci- 
noma, 291 
from orchitis, 290 
from sarcoma, 291 
from tuberculosis, 291 
tuberculosis of, 353 
Tetanus, 247 

in children, 250 
diagnosis of, 250 
differentiation of, 250 

from hydrophobia, 255 
etiology of, 247 
facialis, 250 

from diphtheria antitoxin, 174 
head, 250 
incubation in, 249 
neonatorum, 250 
trismus, 250 
prognosis of, 250 
symptoms of, 249 
treatment of, 251 
vaccination as cause of, 78 
Tetany, 1218 

diagnosis of, 1220 
etiology of, 1218 
in gastric dilatation, 614 
prognosis of, 1220 
symptoms of, 1219 
treatment of, 1220 
thyroid operation causing, 895, 896 
Thomsen's disease, 1222 
Thoracocentesis, 561 
Thrombophlebitis in tuberculosis, 334 
Thrombosis of aorta, 484 
arterial, of brain, 985 
of heart, 451 
portal vein, 722 
of spinal cord, 1083 
venous, in chlorosis, 834 
Thrush, 575 
Thymus asthma, 897 

gland, abscess of, 897 
cyst of, 897 
diseases of, 897 
functions of, 897 
hemorrhage of, 897 
hypertrophy of, 897 
persistence of, 897 
tumors of, 897 
Thyroid extract, 896 

gland, aberrant, 887 
accessory, 887 
cancer of, 887 
chondroma of, 887 
cysts of, 887 
diseases of, 886 
echinococcus of, 887 
goitre, 886 

hypertrophy of, 886, 888 
inflammation of, 887 
myxoma of, 887 
overactivity of, 888 
perversion of, 888 
strumitis, 887 



INDEX 



1323 



Thyroid gland, tumors of, 887 

in typhoid fever, 29 
Thyroidectomy, 892 
Thyroidism, 896 
Thyroiditis, rheumatic, 199 
Tic complex, 1216 
convulsif, 1163 
douloureaux, 1230 
simple, 1215 

with explosive utterances, 1216 
Tinnitus aurium, 1164 
Tobacco, leukoplakia, 577 
Toe phenomenon, 972 
Tongue, cat's, 88 
diseases of, 577 
eczema of, 577 
glossitis, 578 
ichthyosis of, 577 
keratosis of, 577 
leukoplakia of, 577 
psoriasis of, 577 
scarlatinal, 88 
strawberry, 88 
tuberculosis of, 346 
in typhoid fever, 30 
Tonsillar hypertrophy, 587 
Tonsillitis, acute follicular, 584 

complications of, 585 
diagnosis of, 585 
differentiation of, 585 
etiology of, 584 
symptoms of, 585 
treatment of, 586 
chronic, 587 

diagnosis of, 588 
etiology of, 587 
symptoms of, 587 
treatment of, 589 
diphtheria, 163 
in influenza, 178 
rheumatic, 192 
suppurative, etiology of, 586 
symptoms of, 586 
treatment of, 587 
Tonsils, diseases of, 584 
tuberculosis of, 347 
Tophi arthritici, 922, 923 
Tormina ventriculi, 644 
Torticollis, 1172 

rheumatic, 197 
Tourette's disease, 1216 
Toxaemia, tuberculous, 316 
Trachea, diseases of, 495 

stenosis of, etiology of, 504 

symptoms of, 504 
syphilis of, 280 
Tracheal tugging, aneurysmal, 476 
Tracheitis in influenza, 178 
Tracheotomy in diphtheria, 175 

laryngeal perichonditis and typhoid 
35 
Transudates, character of fluid, 761, 762 
Traube's space, 547 

tones, 504 
Trauma, neuroses from, 1199 
of spinal cord, 1086 



Traumatic neuroses, 1199 
Trematodes, diseases caused by, 1275 
Trembles, 374 
Tremor, exophthalmic, 890 
intention, 1105 
varieties of, 1225 
Trichina spiralis, diagnosis of, 1269 
etiology of, 1267 
prognosis of, 1269 
symptoms of, 1268 
treatment of, 1269 
Trichinosis, 1267 

differentiation of, from typhoid 
fever, 46 
Trichocephalus dispar, 1274 
Trichuris trichura, 1274 
Tricuspid insufficiency, 414 
diagnosis of, 416 
etiology of, 414 
mechanism of, 414 
signs of, 415 
stenosis, 417 

congenital, 432 
Trismus, 249, 1157 
Trophic neuroses, 1234 
Trophcedema, hereditary, 1236 
Trousseau's sign, 1219 
Trypanosoma, fever, 1276 
Trypanosomiasis, 1276 
Tubercle bacilli, "acid-fast" bacilli, 499 

of brain, 999 
Tuberculin injections, 331 
Tuberculosis, 303 

of alimentary tract, 346 

of aorta, 356 

arthritis, differentiation, from^arth- 

ritis deformans, 930 
atrium of, 307 

by digestive tract, 308 
by direct inoculation, 308 
by respiratory tract, 308 
of bladder, 352 
of bloodvessels, 356 
of bones, 357 
bovine, 306 
of brain, 346, 999 
of bronchial glands, 339 
choroidal, 1051 
congenital, 309 

differentiation of, from broncho- 
pneumonia, 519 
of ear, 354 
etiology of, 304, 309 
extension of, mode of, 313 
of Fallopian tubes, 353 
of genitalia, 353 
of genito-urinary tract, 350 
of gums, 346 
of heart, 356 
herpes in, 317 

histopathology of tubercle, 312 
of intestines, 348 
etiology of, 34S 
symptoms of, 349 
of joints, 357 

symptoms of, 357 



1324 



INDEX 



Tuberculosis of joints, treatment of, 357 
of kidney, 351 

etiology of, 351 
pathology of, 351 
symptoms of, 351 
general, 352 
local, 352 
urinary, 352 
of larynx, 354 

etiology of, 354 
forms of, 355 
pathology of, 354 
symptoms of, 354 
treatment of, 355 
of lips, 346 
of liver, 350 
of lungs, 318 

in aged, 331 
in children, 330 
complications of, 333 

amyloid degeneration, 336 
circulatory, 334 
digestive, 335 
genito-urinary, 336 
muscular, 334 
nervous, 334 
pneumothorax, 563 
respiratory, 333 
skin, 336 
course of, 327 
diagnosis of, 331 
extension of, 318 
forms of, acute, 327 

desseminated, 328 
galloping, 327 
miliary, 329 
pneumonic, 327 
ulcerative, 329 
chronic, 329 

fibrous phthisis, 329 
pleuritic, 330 
ulcerative, 329 
pathology of, 318 
prognosis of, 332 
stages of, confirmed, 327 
consummated, 327 
incipient, 327 
symptoms of, 319 
general, 322 
physical signs, 323 
respiratory, local, 319 
lymphadenitis, differentiation from 

pseudoleukemia, 863 
•of lymph glands, 337 

bronchial adenitis of, 339 
atrium of, 339 
diagnosis of, 340 
issues of, 340 
signs of, 339 
symptoms of, 339 
cervical adenitis, 338 

atrium of, 338 
pathology of, 338 
symptoms of, 338 
characteristics, 337 
etiology of, 337 



Tubercolosis of lymph glands, general- 
ized adenitis of, 340 
mesenteric adenitis of, 340 
pathology, 337 
treatment of, 340 
of mammae, 353 
measles, as cause of, 99 
of meninges, 346 
of mesenteric glands, 340 
miliary, acute, 313 

diagnosis of, 317 
etiology of, 313 
prognosis of, 318 
remissions of, 318 
symptoms of, 314 

choroidal tubercles, 

316 
circulatory, 315 
digestive, 316 
fever, 315 
nervous, 316 
respiratory, 315 
types, 317 
chronic, 318 

differentiation of, from influ- 
enza, 181 
mixed infection, 305 
of muscles, 357 
of nasopharynx, 354 
of nose, 354 
of oesophagus, 347 
of palate, 347 
of pericardium, 341 
of peritoneum, 341 
course of, 345 
diagnosis of, 345 
etiology of, 342 
symptoms of, 343 
adhesions, 343 
ascites, 344 
exudation, 344 
fever, 344 
friction, 344 
gastro-intestinal, 345 
marasmus, 345 
meteorism, 344 
pain, 345 
palpation, 344 
pelvic effusion, 344 
retraction, 343 
treatment of, 345 
types of, 342 
of pharynx, 347 
of pleura, 341 
prevalence of, in animals, 306 

in man, 306 
prognosis of, results from treatment, 

360 
of prostate, 353 
pseudotuberculosis, 307, 332 
pulmonary, in diabetes, 912 
roseolse in, 317 
of salivary glands, 347 
of serous membranes, 341 
of skin, 323, 358 
of spine, 1071 



INDEX 



1325 



Tuberculosis of spleen, 316, 350, 885 
of stomach, 348 
of suprarenal glands, 877 
of testicle, 353 
of tongue, 346 
of tonsils, 347 
treatment of, 359 
expectant, 363 
anaemia, 366 
cardiants, 365 
cough, 363 

digestive disorders, 365 
dyspnoea, 365 
fever, 363 
haemoptysis, 365 
insomnia, 365 
pain, 365 

sexual symptoms, 366 
sweats, 364 
hygienic, 360 
food, 361 
fresh air, 360 
rest, 362 
prophylactic, 359 

antibacillary, 359 
governmental, 359 
individual, 359 
specific, 362 
in typhoid fever, 36 
of ureter, 352 
urine in, 316 

vaccination as cause of, 78 
Tuberculous anaemia, 311 
arteriosclerosis, 311 
bronchitis, 311 
cirrhosis of liver, 311 
cyanosis, 315 
dyspnoea, 315 
endocarditis, 356 
meningitis, 316, 1049 

differentiation of, from syphilis, 
283 
psychoses, 311 
rheumatism, 357 
spina ventosa, 357 
toxaemia, 316 
valvular disease, 311 
Tuffnell treatment, 480 
Tumor albus, syphilitic, 293 
Tumors of bile-ducts, 742 
of brain, 999 
of gall-bladder, 741 
of heart, 451 
of intestines, 677 
of kidneys, 822 
of larynx, 494 
of liver, 711 

differentiation of, from abscess, 
724 
of lungs, 531 

differentiation of, from pneu- 
monia, 153 
of mediastinum, 569 
of meninges, 1079 
of mesentery, 691 
of oesophagus, 596 



Tumors of pancreas, 749 
of pleura, 569 
of rectum, 677, 679 
renal, differentiation of, from cancer 

of liver, 714 
of spleen, acute, 882 

chronic, 882, 885 
of stomach, 632, 633, 636 
of suprarenal glands, 881 
of thymus gland, 897 
of thyroid gland, 887 
of ureter, 822 
Tussis hepatica, 710 
Tympanites in typhoid fever, treatment 

of, 52 
Typhlitis, tuberculous, 349 
Typhoid fever, 17 

in aged, 40 

anomalous courses of, 38 
bilious, 61 
in children, 39 
chills in, 21, 24 
clinical types of, 19 
convalescence of, 41 
diagnosis of, 41 

etiological, 18 
differentiation of, from anthrax, 
42 
from endocarditis, 44, 45 
from enteritis, 43 
from gastritis, 43 
from malaria, 44, 45 
from meningitis, 44, 45 
from miliary tuberculosis, 

42, 44, 45, 317 
from paratyphoid, 43 
from pernicious malaria, 

123 
from pneumonia, 42 
from sepsis, 44, 45 
from septic affections, 135 
from serous meningitis, 

1055 
from trichinosis, 46 
from typhus fever, 42, 60 
etiology of, 17 

bacillus typhosus, 17 
predisposing, 18 
exacerbations of, 140 
gall-stones in, relation of, 728 
immunity from, 19 
incubation of, 19 
onset of, 20 
paratyphoid, 19, 43 
prognosis of, 46 
recrudescences of, 41 
relapses of, 40 
"scarlet-typhoid," 89 
second attacks of, 19 
sudoral type of, 21, 24 
symptoms of, 19 
bone, 29 
cardinal, 41 
circulatory, 24 
contra-indicating. 42 
dermal, 23 



1326 



INDEX 



Typhoid fever, symptoms of, digestive 
tract, 30 
fever, 20 

genito-urinary, 36 
joint, 29 
muscle, 29 
nervous, 27 
respiratory, 35 
secondary, 42 
special senses, 29 
splenic tumor, 22 
thyroid gland, 29 
treatment of, 47 
antipyresis, 49 
antiseptic, 48 
of bacilluria, 55 
of bed-sores, 55 
care of skin, 55 
of convalescence, 55 
diet, 50 

of epistaxis, 54 
expectant, 52 
hygienic, 48 
of laryngeal lesions, 54 
of nervous symptoms, 54 
prophylactic, 47 
specific, 48 
symptomatic, 52 
of thrombophlebitis, 54 
spine in typhoid fever, 29 
state, 27 
Typhus fever, 55 

differentiation of, 59 

from measles, 101 
etiology of, 56 
exanthematous, 55 
prognosis of, 60 
recurrence of, 59 
symptoms of, 56 
general, 56 

defervescence, 57 
exanthematous stage, 

56 
incubation, 56 
invasion stage, 56 
special, 57 

alimentary, 59 
circulatory, 58 
fever, 57 

genito-urinary, 59 
glands, 59 
nervous, 58 
respiratory, 58 
skin, 57 
spleen, 59 
treatment of, 61 
icteroids, 216 

recurrens. See Recurrent Fever, 61 
Tyrotoxismus, 1252 



U 



Ulcers, bronchial, syphilitic, 280 
duodenal, 655 



Ulcers, gastric, differentiation of, from 
gall-stones, 733 
of intestines, 655, 657 

in tuberculosis, 335 
of larynx, 494 

in typhoid fever, 35 
of oesophagus, 590 
of pharynx, 583 
of stomach, round, 617 
typhoid, of appendix, 31, 32 
of oesophagus, 31 
of pharynx, 31 
of stomach, 31 
Ulcerative stomatitis, 574 
Ulcus perforans of stomach, 618 
rotundum of stomach, 618 
simplex of stomach, 618 
Uncinaria duodenalis, etiology of, 1269 
symptoms of, 1270 
treatment of, 1272 
Uncinariasis, 1269 
Uraemia, 781 

acute, treatment of, 773 
causes of, 781 
coma from, 976 
diagnosis of, 784 
differentiation of, 784, 785 
etiology of, 781 
latent, 820 
scarlatinal, 89, 95 
symptoms of, 782 
cardiac, 783 
digestive, 783 
nervous, 782 
respiratory, 783 
treatment of, 785-791 
in yellow fever, 217 
Urates in urine, 807 
Ureter, calculus of, 822 
tuberculosis of, 352 
tumor of, 824 
Urethritis in mumps, 189 
Uric acid, calculus, 817 

in urine, 807 
Urine, albumin in, 799 
alkaptone in, 808 
blood in, 802 
chyle in, 806 

in cirrhosis of liver, 699, 705 
cryoscopy of, 780 
fat in, 806 
febrile, 36 

hsematoporphyrin in, 809 
in heart disease, 421 
hydrochinon in, 809 
in icterus, 726 
indican in, 808 
in nephritis, 768 
oxalates in, 808 
phosphates in, 807 
pus in, 805 
tests of, elimination, 780 

permeability, 780 
in tuberculosis, 316 
urates in, 807 
uric acid in, 807 



INDEX 



1327 



Urine in yellow fever, 217 
Urobilin, icterus, 725 
Urobilinuria, 726 
Urostealiths, 818 
Urticaria, visceral crises in, 867 
Uterus, syphilis of, 291 



Vaccination, 64, 77, 78, 79 
Vaccinia, 77 
Vagina, syphilis of, 291 
Valsalva's experiment, 384 
Valvular disease, chronic, 401. See 
Aortic Insufficiency, etc. 
general symptoms of, 418 
tuberculous, 311 
heart disease. See Aortic Insuffi- 



< 



ciency, etc. 
Varicella, 81 



differentiation of, from smallpox, 74 
Variola, 64 

differentiation of, from measles, 101 
Vas deferens, syphilis of, 291 
Vasomotor neuroses, 1234 
Veins, syphilis of, 278 
Venesection, 158 

in apoplexy, 978 
in cardiac disease, 425 
Ventricles, cerebral, hemorrhage in, 976 
Vertebrae, carcinoma of, diagnosis of, 
1075 
symptoms of, 1075 
caries of, 1071 

diagnosis of, 1074 
etiology of, 1071 
localization of, cervical,- 1072 
dorsal, 1072, 1073 
lumbar, 1074 
pathology of, 1071 
prognosis of, 1074 
symptoms of, 1072 
treatment of, 1075 
diseases of, 1068 
dislocation of, 1070 
fracture of, 1068 
course of, 1070 
diagnosis of, 1070 
etiology of, 1068 
symptoms of, 1069 
treatment of, 1070 
tuberculosis of, 1071 
Vertigo, auditory, 1165 
cerebellar, 960 
e stomacho lseso, 605 
Vincent's angina, 170, 583 
Visceral rheumatism, 194 
Visceroptosis, 680 
Vision, centre for, 946 
Visual centre, 946 
Vocal cords, paralysis of, 1168, 1169, 

spasm of, 1169 
Volvulus, 612 

diagnosis of, 675 
differentiation of, 676 



Volvulus, etiology of, 672 

pathology of, 672 

symptoms of, 673 

treatment of, 676 
Vomiting, in brain tumor, 1002, 1008 

in cholera asiatica, 209 

differentiation of, 645 

in gastric cancer, 632 

in gastric ulcer, 619, 620, 621 

nervous, 645 

causes of, 645 
differentiation of, 645 

in pneumonia, 146 

in tuberculosis, 335 

in typhoid fever, 30 

treatment of, 52 
Vomitus, coffee-grounds, 620 

cruentus, 638, 637 
V. Eiselsberg's sign, in hour-glass stom- 
ach, 617 
Voussure, pericarditic, 380 
Vulva, syphilis of, 291 
Vulvovaginitis, diphtheritic, 166 



W 



Wandering liver, 719 
War fever, 655 
Weber's test, 639 
Weil's disease, 372 

diagnosis of, 373 
etiology of, 373 
prognosis of, 373 
symptoms of, 373 
treatment of, 374 
Werlhof s disease, 868 
Westphal's sign, 1118 
Whip-worm, 1274 
Whooping-cough, 182 

"after-pertussis," 185 
complications of, 184 
bronchitis, 184 
bronchopneumonia, 184 
convulsions, 184 
glottis, spasm of, 184 
hemorrhages, 184 
oedema, 184 
pneumonia, lobar, 184 
course of, 184 
diagnosis of, 185 
differentiation of, 185 
from croup, 185 
from false croup, 185 
from glottis, spasm of, 185 
from hysteria, 185 
from laryngeal disease, 185 
from periodic asthma, 185 
etiology of, 182 
prognosis of, 186 
sequels of, 185 
symptoms of, 183 

convulsive stage, 1S3 
decline, 183 
toxaemia . 185 
vomiting. 184 



1328 



INDEX 



Whooping-cough, treatment of, 186 
hygienic, 188 
intubation, 187 
medicinal, 186 
prophylaxis, 186 
in typhoid fever, 26 
Williamson's test of diabetic blood, 912 
Winckel's disease, 869 
Wintrich change of note, 326 

of pitch in pneumonia, 144 
palpatory percussion in pneumonia, 
144 
Wolfler's sign, in hour-glass stomach, 

617 
Wooden-tongue, 257 
Woolsorters' disease, 243 
Word deafness, 947, 948, 949, 950 
Wound diphtheria, 166 
Writer's cramp, 1221 

diagnosis of, 1221 
etiology of, 1221 
symptoms of, 1221 
treatment of, 1221 
Writing, disturbances in, 948, 952 
Wryneck, 1172 



Xanthin calculus, 818 
Xanthoma in icterus, 728 
Xanthopsia in icterus, 728 
Xerostomia, 579 



Yellow atrophy of liver, acute, 692 
fever, 213 

complications of, 217 

diagnosis of, 217 

epidemiology, 214 

etiology of, 213 

sequels of, 217 

prognosis of, 218 

symptoms of, general, 214 
incubation, 214 
stages of, 214, 215 
special, 215 

black vomit, 216 
circulatory, 216 
digestive, 216 
fever, 215 
hemorrhages, 217 
icterus, 216 
liver, 216 
nervous, 215 
respiratory, 216 
urine, 217 
vomito-negro, 216 

treatment of, 218 



ZOMOTHERAPY, 362 

Zoonoses, 239 
Zuckergussleber, 758 



MAY 1 1907 



LIBRARY OF CONGRESS 



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